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Digitized  by  tine  Internet  Archive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/manualforhealthoOOmacn 


A  MANUAL 

FOR 

HEALTH  OFFICERS 

BY 

J.    SCOTT    MacNUTT,   A.B.,  S.B. 

Sometime  Health  Officer  of  Orange,  New  Jersey,  and  Member  of  the  Board 

of  Examiners  of  Health  Officers  and  Sanitary  Inspectors  of 

New  Jersey;  Lecturer  on  Public  Health  Service  in 

the  Massachusetts  Institute  of  Technology 

WITH    A 

FOREWORD 

BY 

WILLIAM   T.    SEDGWICK 

Professor  of  Biology  and  PubHc  Health  in  the  Massachusetts 
Institute  of  Technology 


FIRST   EDITION 

FIRST    THOUSAND 


NEW   YORK 

JOHN    WILEY    &    SONS,    Inc. 

London:    CHAPMAN   &  HALL,   Limited 

1915 


Copyright,  1915 

BY 

J.  SCOTT  MacNUTT 


Stanbope  ]Press 

F.    H.GILSOIV    COMPANY 
BOSTON,  U.S.A. 


PREFACE 


The  aim  of  this  volume,  as  a  general  guide  for  health 
officers,  is  clearly  indicated  in  the  Foreword.  Its  scope, 
however,  as  the  work  progressed,  has  been  enlarged  over 
that  of  a  simple  manual  by  the  inclusion  of  a  considerable 
amount  of  reference  matter  which  it  was  thought  should  be 
thus  readily  available.  And,  while  the  needs  of  the  local 
health  office  have  dictated  the  content,  certain  portions  of 
the  volume  —  e.g.,  those  summarizing  tuberculosis,  infant 
hygiene  and  publicity  work  —  may  be  of  service  to  persons 
engaged  in  the  work  of  unofficial  organizations  concerned 
with  those  subjects. 

Emphasis  has  been  placed  upon  practical  administration, 
the  more  abstract  principles  of  sanitary  science  being  pre- 
supposed. So  far  as  possible  definite  procedures  are  given, 
but  in  regard  to  the  many  matters  on  which  no  such  pro- 
cedure can  at  present  writing  be  positively  deduced,  an 
effort  has  been  made  to  indicate  the  chief  considerations  at 
issue. 

References,  suggestive  rather  than  exhaustive,  are  fre- 
quently given,  not  only  to  substantiate  specific  statements, 
but  also  to  serve  as  indications  for  further  study  along 
particular  lines.  On  page  98  is  given  a  list  of  the  literature 
of  chief  general  interest  to  the  health  officer. 

In  the  three  principal  needs  in  the  public  health  field 
today  —  (i)  scientific  definition  of  principles  of  procedure, 
(2)  improved  organization  and  (3)  trained  sanitary  officers 
—  progress  is  being  made.  Not  only  is  this  observable  in 
individual  cities  and  towns,  but  in  the  advances  in  the 
sanitary  systems  of  whole  states.     A  recent  example  of 


IV  PREFACE 

this  is  to  be  seen  in  the  recent  reorganization  in  New  York 
State  with  the  conferring  upon  the  State  authorities  of  local 
supervisory  powers  and  the  adoption  of  a  State  sanitary 
code.  To  such  developments,  which  cannot  be  treated  in 
detail  in  such  a  volume  as  the  present,  attention  is  called, 
as  most  clearly  exemplifying  the  present-day  public  health 
movement. 

Aside  from  many  sources  of  data  which  cannot  be  par- 
ticularized here,  special  acknowledgment  is  due  for  the 
courtesy  of  Dr.  M.J.  Rosenau  and  his  publishers,  Messrs.  D. 
Appleton  and  Company,  in  permitting  the  use  of  consider- 
able excerpts  on  disinfection  from  his  work  "Preventive 
Medicine  and  Hygiene"  (1913);  also  to  Professor  G.  C. 
Whipple  for  extracts  on  epidemiology  from  his  "  Typhoid 
Fever"  (1908).  Particular  thanks  are  due  to  Mr.  Franz 
Schneider,  Jr.,  of  the  Department  of  Surveys  and  Exhibits 
of  the  Russell  Sage  Foundation,  for  reading  the  entire  manu- 
script and  making  many  useful  suggestions.  Advantageous 
criticism  on  the  subject  of  publicity  was  also  received  from 
Mr.  E.  G.  Routzahn,  Director  of  the  above-mentioned 
Department.  To  Professor  W.  T.  Sedgwick,  of  the  Massa- 
chusetts Institute  of  Technology,  the  author  is  indebted 
for  the  original  suggestion  from  which  the  present  work 
took  its  inception,  as  well  as  for  subsequent  advice  and 

encouragement. 

J.  S.  M. 

Boston,  April,  1915. 


FOREWORD 


Some  three  years  ago  when  the  author  of  this  book 
(whom  I  am  glad  to  be  able  to  claim  as  a  former  pupil) 
was  serving  as  the  Health  Officer  of  Orange,  New  Jersey,  I 
urged  upon  him  the  importance  of  preparing  a  Manual  or 
Handbook  which  should  do  for  health  officers  what  the 
various  handbooks  for  civil  engineers,  mechanical  engi- 
neers and  other  technicians  do  for  persons  engaged  in 
those  professions.  Fortunately,  in  1913,  Mr.  MacNutt  was 
enabled  to  withdraw  from  his  official  position  and,  after 
devoting  a  year  of  quiet  labor  to  the  task,  has  now  com- 
pleted the  first  edition  of  a  manual  such  as  I  had  in  mind. 
This,  I  believe,  will  be  of  great  service  to  health  authori- 
ties of  every  kind,  who  will  here  find  carefully  laid  down 
the  fundamental  data  of  their  profession,  and  to  all  such 
I  therefore  heartily  commend  it. 

At  the  end  of  the  nineteenth  century  the  public  health 
officer  when  he  existed  at  all  was  generally  merely  a  phy- 
sician who  had  assumed  the  title  and  who  gave  to  the  office 
only  a  small  part  of  his  time.  Of  any  special  training  for 
public  health  work  he  was  blissfully  innocent.  Of  water 
supply,  sewerage,  milk  supply,  insects,  infant  mortality, 
school  hygiene  statistics,  ventilation  and  similar  topics  so 
indispensable  today  he  had  little  or  no  knowledge.  His 
interest  began  —  and  too  often  ended — at  the  bedside  and 
the  hospital.  But  with  the  recent  remarkable  development 
of  sanitation,  preventive  medicine  and  hygiene;  with  the 
recognition  of  the  significance  of  pure  milk,  pure  water, 
pure  air  and  pure  food;  with  the  modern  emphasis  upon 
the  transmission  of  disease  by  insects  and  by  carriers ;  and 


vi  FOREWORD 

with  the  growth  of  sanitary  law  and  Federal,  state  and 
municipal  regulations,  the  problems  and  practices  of  health 
authorities,  whether  physicians  or  laymen,  have  become 
so  highly  technical  as  to  require  special  preparation  and 
technical  knowledge.  Hence  it  is  not  too  much  to  say 
that  within  the  last  decade  a  new  profession  has  arisen 
in  America,  namely,  that  of  the  trained  and  full-time  health 
officer. 

For  health  officers,  boards  of  health,  and  all  other 
health  officials  Mr.  MacNutt's  Manual  will  be  of  imme- 
diate practical  value.  To  the  beginner  it  will  be  espe- 
cially helpful  since  it  virtually  records  the  practical  results 
of  the  author's  personal  experience  in  the  profession.  For 
students  in  training,  such  as  members  of  schools  for 
health  officers,  and  for  students  pursuing  special  courses  in 
public  health  science  in  medical,  scientific  and  technologi- 
cal Schools  it  should  serve  also  as  an  indispensable  guide 
to  those  subjects  requiring  most  careful  consideration. 

William  T.  Sedgwick 


CONTENTS 


PART  I 
HEALTH  AUTHORITIES:  THEIR  ORGANIZATION  AND  POWERS 


CHAPTER   I 

Page 

Local  Health  Authorities i 

Organization,  4;   Powers  and  Procedure,  8;  Staff,  12;   Nature 
of  Sanitary  Authority,  24;   Administration,  27. 

CHAPTER   II 
State  Health  Authorities 31 

Advisory  Functions,  32;    Executive  Functions,  39;    Organi- 
zation, 46. 

CHAPTER   III 

Federal  Health  Authorities 52 

Advisory  Functions,  52;    Executive  Functions,  53;    Federal 
Bureaus,  54;    Proposed  National  Health  Service,  56. 

CHAPTER   IV 

Unofficial  Organizations 59 

National,  60;    International,  65;    State,  65;    Local,  67. 

CHAPTER  V 

The  New  Public  Health 69 

Public  Health  Science,  69;    Problems,  71;    The  Old  Public 

Health,  82;   The  New  Public  Health,  88. 
General  References,  98. 

vii 


Mil  CONTENTS 


PART    II 
PUBLIC   HEALTH  ADMINISTRATION 


CHAPTER    I 

Page 

Communicable  Disease loi 

Terms  and  Classification,  loi ;  Control,  102;  Modern  Theory 
of  Infection,  106;   Sources  and  Modes  of  Infection,  112. 

/.  Diseases  Spread  Largely  through  Secretions  or  Discharges 
from  Nose,  Throat  or  Mouth,  123.  Diphtheria,  136; 
Scarlet  Fever,  147;  Measles,  150;  German  Measles,  154; 
Whooping  Cough,  154;  Lobar  Pneumonia,  155;  Cere- 
brospinal Fever,  157;  Tuberculosis,  158;  Other  Diseases, 
186. 

//.  Diseases  Spread  Largely  through  Excreta.  Typhoid  Fexer, 
187;  Cholera,  203;  Dysenteric  Diseases,  204;  Hookworm 
Disease,  205. 

///.  Diseases  Spread  by  Insects  and  Vermin,  206.  Mosquito- 
borne  Diseases:  Malaria,  207;  Yellow  Fever,  208. 
Fly-borne  Diseases,  209.  Other  Insect-borne  Diseases: 
Plague,  etc.,  210. 

IV.  Diseases  Having  Specific  or  Special  Preventive  Measures. 
Smallpox,  211;  Rabies,  218;  Venereal  Disease,  233. 
Preventable  Blindness:  Ophthalmia  Neonatorum,  239; 
Trachoma,  242. 

V.  Miscellaneous  Diseases.  Infantile  Paralysis,  243;  Chick- 
enpox,  245;  Septic  Sore  Throat,  245;  Tetanus,  246; 
Glanders,  248;  Anthrax,  250;  Pellagra,  251;  Leprosy 
(Lepra),  252;   Mental  and  Other  Diseases,  253. 

The   Schools   in    Relation   to   Communicable    Disease,    254; 

School    Hygiene   and   Sanitation,    261;     Libraries,   263; 

General  Regulations  against  Contact  Infection,  264. 
Epidemiology,  with  Examples  of  Epidemics,  266. 
General  References,  293. 

CHAPTER    II 

Child  Hygiene 296 

Medical  Inspection  and  Sanitation  of  Schools,  296;  Infant 
Hygiene,  300;  Organization  of  Infant  Il\gicne  Work,  333. 


CONTIONTS  IX 

CHAPTER    III 

Pa'.k 

Milk  and  Other  Food  Supplies 345 

/.  Milk.  General  Reciuirements,  345;  Regulation  of  Milk 
Supplies,  361. 

//.    Foods  Other  than  Milk,  398. 

CHAPTER   IV 

Water  Supplies 405 

Inspection,  405;  Analysis,  405;  Public  Supplies,  408;  Private 
Supplies,  414.     Ice  Supplies,  418. 

CHAPTER  V 

Housing  and  Industrial  Hygiene 420 

Housing,  421.     Industrial  Hygiene,  434. 

CHAPTER  VI 

Nuisances 439 

General  Considerations,  439;  Disposal  of  Excreta,  448; 
Other  Wastes,  458;  Fly  Suppression,  461;  Mosquito 
Suppression,  468;    Miscellaneous  Nuisances,  475. 

CHAPTER  VII 
Sanitary  Law 480 

CHAPTER  VIII 
The  Annual  Report 486 

CHAPTER   IX 

Vital  Statistics 489 

Registration,  492;  Theory,  499;  Population,  503;  Deaths, 
507;  Marriages,  519;  Births,  519;  Stillbirths,  523; 
Morbidity  Statistics,  523;  Sources  of  Statistical  Error, 
524;  Methods,  529;  Presentation  of  Results,  534;  Prac- 
tical Application,  539. 


X  CONTENTS 

CHAPTER  X 

Page 

Publicity 542 

General  Considerations,  542;  The  Press,  546;  Printed 
Matter,  552;  Exhibitions,  556;  Small  Exhibits,  564; 
Lectures,    564;     Motion    Pictures,   567;     Publicity  and 

Administration,  568. 

APPENDIXES 

A.  Disinfection  and  Disinfectants 569 

Terms,  569;  Disinfectants,  570;  For  Specific  Uses,  581; 
Standardization,  589;  Household  Disinfectants  and 
Deodorants,  590. 

B.  Standard  Rules  for  Milk  Supplies 594 

C.  Legal  Decisions  Regarding  Tuberculin  Test 604 

D.  Health  Department  Laboratory 608 

E.  Rules  of  Statistical  Practice 612 

F.  Cooperative  Health  Administration  Among  Small  Communities  619 

G.  Standard  Plan  for  Annual  Reports 622 

H.    List  of  Health  Office  Forms 629 

/.    Extracts  from  New  York  State  Sanitary  Code 632 

I NDEX 635 

CHARTS 

1 .  Death  Rates  by  Ages 74 

2.  Death  Rates  for  Chief  Preventable  Diseases 76 

3.  Showing  Relation  of  Milk   Routes  to  Scarlet  Fever   During 

Outbreak  at  Norwalk,  Conn.,  1897 283 

4.  The  Problem  of  Infant  Mortality 301 


PART   I 

HEALTH    AUTHORITIES 
THEIR    ORGANIZATION    AND    POWERS 


A   MANUAL 
FOR   HEALTH   OFFICERS 


CHAPTER   I 
LOCAL  HEALTH  AUTHORITIES  • 

The  chief  basis  of  sanitary  authority  in  any  community 
is  essentially  local.  That  authority  is  commonly  vested 
in  the  local  board  of  health  and  its  officers,  although 
in  some  small  communities  where  no  such  board  is  ap- 
pointed the  sanitary  authority  is  exercised  by  the  select- 
men, township  committee  or  other  governing  body.  The 
local  board  of  health  was  in  origin  the  earliest,  and  is  now 
in  operation  the  most  powerful,  sanitary  unit. 

In  all  except  the  most  undeveloped  and  primitive  com- 
munities, boards  of  health  entrust  their  executive  work  to 
a  staff  headed  by  a  "  health  officer  "  (or  "  health  inspec- 
tor" ;  sometimes  "  health  commissioner  "),  who  is  as- 
sisted by  subordinate  sanitary  inspectors  and  other  em- 
ployees. The  health  officer  attends  to  matters  of  routine 
and  takes  such  executive  action  as  he  may  be  empowered 
to  take  between  sessions  of  the  board.  The  board  retains 
a  directive  power:  makes  regulations,  prescribes  the  gen- 
eral manner  of  their  enforcement,  and  decides  important 
questions  of  administrative  policy  and  procedure.  Thus 
the  fundamental  authority  and  responsibility  reside  in 
the  board  and  are  exercised  by  the  health  officer  only  in 
so  far  as  they  are  delegated  to  him  by  the  board. 

3 


4  A  MANUAL   FOR   HEALTH  OFFICERS 

LOCAL  ORGANIZATION 

The  Health  Officer  and  the  Board. —  The  health 
officer,  staff  and  board  constitute  the  department  of  health 
of  any  community.  The  terms  "  health  department  " 
and  "  health  authorities  "  will  be  given  preference  in  these 
pages,  not  only  as  being  the  most  inclusive  terms,  but  — 
and  cliiefly  —  to  indicate  that  the  most  important  factor 
is  not,  as  popularly  supposed,  the  board  of  health,  but  the 
trained  health  officer  and  his  staff.  In  fact,  it  is  main- 
tained by  many  who  have  observed  the  practical  workings 
of  health  authorities  that  the  majority  of  local  boards  of 
health  are  weakened  by  political  interference,  or  are  at 
any  rate  incapable  of  dealing  intelligently  with  the  techni- 
cal details  of  administration  which  come  before  them,  and 
it  has  been  asserted  by  some  that  they  could  to  great  ad- 
vantage be  abolished  and  their  powers  be  turned  over 
bodily  to  a  well-trained,  expert  health  officer.  The  average 
local  board  of  health,  it  is  urged,  does  not  mend  the  acts 
of  an  inefficient  health  officer,  while  to  the  expert  health 
officer  it  may  be  a  positive  hindrance,  blocking  despatch 
and  putting  a  damper  on  effective  administration. 

It  is  indeed  true  that  the  expert  health  officer,  with 
an  expert  staff,  is  the  chief  figure  in  public  health  admin- 
istration to-day.  It  is  he,  and  not  the  board,  who  initiates 
and  who  executes;  it  is  he  only  who  can  have  that  intimate 
and  exact  knowledge  of  principles  and  conditions  which  is 
necessary  for  effective  action,  nor  is  there  any  question 
that  the  average  board  of  health  is  a  body  incompetent  to 
pass  upon  such  details. 

There  is,  however,  another  view  of  the  matter,  — 
namely,  that  the  board  acts  as  a  mediator  between  the 
public  and  the  health  officer.  As  a  body  it  is  (or  should 
be)  fitted  to  deal  with  those  large  questions  of  sanitation 
which  affect  public  standards  —  sanitary,  social,  economic, 
and  other  —  in  an  important  degree.     Such  questions  are 


T/3CAL  HEALTH   AUTHORFrilOS  5 

in  the  final  decision  non-technical  in  nature,  framing  them- 
selves in  the  form:  Granted  that  such-and-such  a  step  will 
bring  a  certain  degree  of  benefit  to  the  pul)lic  health,  is  it 
worth  the  costs  —  in  money  and  otherwise  —  entailed? 

In  rural  districts,  where  a  state  or  county  code  can  be 
drawn  up  for  large  areas,  it  is  doubtless  best  that  (as  out- 
lined in  Chapter  II)  local  boards  of  health  be  abolished  and 
that  the  health  officer  be  made  accountable  to  expert  state 
or  county  authority.  But  in  towns  and  cities,  which  have 
a  greater  degree  of  civic  individuality,  the  board  seems 
likely,  for  the  present  at  least,  to  remain.  It  acts  as  a 
check  on  the  health  officer,  preventing  him  from  putting 
impracticable  schemes  into  effect,  but  at  the  same  time 
giving  him  the  backing  of  its  prestige  in  difficult  cases.  It 
may,  by  acting  in  a  quasi- judicial  capacity,  prevent  cases 
from  going  to  law.  It  may  secure  the  cooperation  of 
other  official  bodies  more  readily  than  could  the  health 
officer  alone,  and  obtain  appropriations  more  readily. 
Under  a  commission  form  of  government  boards  of  health 
are  naturally  and  possibly  with  advantage  done  away  with, 
but  under  present  conditions  in  most  communities  their 
abolition  does  not  seem  advisable.  Inefficiency  of  boards 
simply  indicates  that  their  personnel  should  be  improved 
through  higher  civic  standards  and  better  appointments. 
The  appointment  of  members  for  political  reasons  and  not 
for  qualifications  is  at  present  the  chief  evil. 

Those  who  urge  the  abolition  of  boards  of  health  should 
consider  the  question  of  accountability.  While,  in  order 
to  secure  prompt  and  effective  action,  the  expert  health 
executive  should  undoubtedly  be  given  a  wide  range  of 
discretion  in  dealing  with  matters  for  which  a  general 
course  has  already  been  laid  down,  he  must  nevertheless 
be  subject  ultimately  to  some  extrinsic  control.  The 
question  therefore  is,  what  that  control  should  be.  In 
those  instances  where  the  board  has  been  abolished  he 
still  remains  responsible  to  a  superior  body  or  officers  — 


6  A  MANUAL   FOR   HEALTH    OFFICERS 

as,  for  example,  under  the  New  York  plan  of  supervisors  or 
under  a  commission  form  of  government  —  besides  being 
governed  by  a  code  of  sanitary  laws  established  by  supe- 
rior authority. 

Organization  of  Local  Boards  of  Health.  —  While  not 
ahva>s  a  popularly'  elected  body  tlie  board  nevertheless 
represents  the  public  in  that  it  acts  as  mediator  between 
health  officer  and  public.  As  remarked  above,  the  board  is 
the  judge  of  the  «o;/-technical  aspects  of  a  question,  just 
as  the  health  officer  is  the  judge  of  its  technical  aspects. 
Thus  acting,  the  board  is  by  no  means  an  expert  body. 
Its  members  need  simply  be  intelligent  citizens  who  will 
understand  thoroughly  and  judge  wisely  the  proposals  and 
cases  brought  before  them. 

Composition 

The  special,  or  professional,  qualifications  of  the  individ- 
ual members,  though  frequently  important,  are  secondary. 
It  is  seldom  that  the  board  can  be  anything  approach- 
ing an  expert  commission,  and  almost  all  expert  advice 
needed  must  be  furnished  by  the  health  officer.  It  is  cus- 
tomary to  consider  physicians  as  best  fitted  to  serve  on 
the  board  of  health,  and  it  is  desirable  that  that  profession 
be  represented  by  one  member  at  least,  particularly  if  the 
health  officer  himself  be  not  a  medical  man.  It  is  an  error, 
however,  to  make  the  board  a  medical  monopoly,  as  is 
sometimes  done,  and  laws  so  tending  should  be  abolished. 
The  cooperation  of  the  medical  profession,  and  to  a  cer- 
tain extent  its  advice,  are  required,  but  not  entire  control 
by  it.  There  are  other  things  to  be  considered.  For 
example,  questions  of  drainage,  water-supply,  and  the  like 
not  infrequently  arise,  and  it  may  be  well  that  one 
member  of  the  board  be  a  sanitary  engineer,  especially 
if  the  advice  of  the  town  or  city  engineer  be  not  readily 
available.  Plumbing  inspection  is  sometimes  unduly  pre- 
dominant and  that  trade  given  undue  prominence  on  the 


LOCAL  HEALTH   AUTHORI'JIES  7 

health  board.  As  elsewhere  pointed  out,  plumbing  inspec- 
tion is  relatively  unimportant  from  the  health  standpoint 
and  is  best  assigned  to  some  other  city  department,  in 
which  case  no  attention  need  be  paid  to  it  in  the  organi- 
zation of  the  board  of  health. 

The  members  may  properly  be  appointed  by  the  mayor, 
and  to  limit  responsibility  for  the  appointments  it  is  prob- 
ably best  that  they  be  not  subject  to  confirmation  by  the 
common  council  or  other  governing  body.  The  board 
should  be  as  small  as  possible  —  not  over  five  members  — 
for  experience  seems  to  indicate  that  the  larger  boards  are 
less  likely  to  be  harmonious  and  effective.  The  health 
ofilicer  should  not  be  a  member  of  the  board,  for  in  that 
case  he  would  be  placed  in  the  inconsistent  position  of 
voting  on  his  own  acts  and  proposals.  On  the  whole  it  is 
best  to  make  the  health  board  as  distinct  a  body  as  possible 
without  including  in  it  (as  has  been  suggested)  the  mayor 
and  the  heads  of  other  city  departments,  for  these  ofhcials 
have  their  own  distinct  interests  which  are  only  indirectly 
connected  with  health  administration. 

Status 

The  health  board  should  have  full  executive  powers  and 

not  be  emasculated  by  limitation  to  merely  legislative  and 

advisory  functions.     It  should  not  be  responsible  to  the 

council  or  any  other  body  for  its  acts,  so  long  as  these  are 

within  the  powers  conferred  by  law,  and  should  be  entitled 

to  at  least  a  certain  minimum  appropriation.     It  should 

have  entire  control  of  the  appointment  of  its  employees, 

including  the  health  officer.^     Some  general  supervision  by 

'^  In  New  Jersey  a  statute  requires  that  the  council  or  other  local 
governing  body  appropriate  to  the  local  board  of  health  at  least  a  cer- 
tain annual  minimum  sum  (ten  cents  per  capita  of  population,  which, 
however,  is  very  insufficient  for  the  needs  of  the  average  community). 
In  that  State  it  has  also  been  ruled  that  boards  of  health  are  not 
merely  municipal  boards  bearing  an  accountability  to  the  council  or 
other  local  governing  body,  but  that  once  the  latter  has  appointed  the 
board  and  granted  an  appropriation  it  has  no  further  control.  Needless 
to  say,  however,  there  should  be  full  cooperation  between  the  bodies. 


8  A   MANUAL   rOR   IIKALTII   OFFICERS 

State  health  departments  over  the  standards  maintained 
by  local  boards  is,  however,  desirable. 

It  does  not  seem  advisable  that  members  be  remunerated 
for  attendance  at  meetings,  for  much  of  the  best  service  is 
rendered  by  unpaid  boards,  while  the  absence  of  fees  re- 
moves an  inducement  to  make  the  appointments  political 
prizes.  In  order  to  secure  the  benefits  of  experience  the 
terms  should  be  three  years  or  more,  not  expiring  simul- 
taneously, and  members  should  be  eligible  for  re-appoint- 
ment. Meetings  should  be  open  to  the  public  and  "press" 
except  when  very  unusual  circumstances  may  render  "  exec- 
utive session  "  desirable. 

LOCAL  POWERS  AND  PROCEDURE 

The  activities  of  the  local  authorities  are  essentially 
executive.  Legislative  power,  strictly  speaking,  they  have 
not,  for  any  regulations  which  they  may  make  can  only 
be  in  amplification  and  not  in  extension  of  fundamental 
statutes.  Nor  have  they  judicial  power,  for  their  deci- 
sions are  not  binding  until  passed  upon  by  a  court  of  law; 
they  cannot  decide  their  own  legal  suits  nor  impose  pen- 
alties. 

The  first  requisite  for  the  exercise  of  authority  is  legal 
right.  In  the  case  of  the  board  of  health  that  right  is 
based  entirely  on  the  will  of  the  state  legislature  as  ex- 
pressed in  the  public  health  statutes.  It  must  ever  be 
borne  in  mind  that  the  board  cannot  rightfully  issue  any 
order  nor  perform  any  action  which  is  not  authorized,  either 
expressly  or  implicitly,  by  the  organic  law  of  the  state. 

The  board  may  and  should  exercise  its  statutory  powers 
in  two  ways.  First,  it  may  act  directly  upon  such  pro- 
visions of  the  statute  law  as  directly  provide  for  the  action 
in  question.  As  a  rule,  however,  public  health  statutes 
make  few  specific  provisions,  but  are  couched  in  such  gen- 
eral terms  that  to  rely  directly  upon  them  in  executive 
action  is  an  uncertain  or  inadequate  proceeding.     Hence 


LOCAL   lU'AL'ni   AUTHORITIES  9 

it  is  customary  for  local  boards  to  adopt  local  ordinances 
or  regulations  (sometimes  called  collectively  the  "  sanitary 
code  "  or  "  health  code  ")  based  upon  and  amplifying  in 
detail  the  general  provisions  of  the  statutes.  Without 
such  ordinances  effective  local  work  is  impossible.  The 
great  advantage  of  such  ordinances  is  that  they  may  read- 
ily be  framed  to  suit  local  conditions  and  standards.  Such 
ordinances  have  all  the  force  of  law  except  as  they  may 
be  disapproved  on  legal  grounds  when  tested  in  courts  of 

law. 

Procedure 

Having,  then,  a  legal  basis  to  work  on,  the  health  author- 
ities must  first  make  inspections  and  examinations  in  order 
to  determine  whether  or  not  conditions  within  its  juris- 
diction conform  to  the  provisions  of  the  sanitary  law. 
Such  investigation  may  take  any  form  so  long  as  it  is 
reasonable  and  has  a  legitimate  object  in  the  protection  of 
the  public  health.  This  function  implies  of  course  the 
"  right  of  entry,"  i.e.,  to  enter  at  proper  times  into  and 
upon  all  premises  for  the  performance  of  duty,  to  be  en- 
forced by  search  warrant  if  necessary.  It  also  implies  the 
right  to  examine  persons  in  order  to  make  diagnoses  and 
the  right  to  keep  such  persons  under  observation  if  advis- 
able. Again,  it  implies  the  right  to  take  and  examine 
bacteriological  specimens,  such  as  diphtheria  cultures,  of 
various  kinds;  and  to  collect  and  examine  specimens  of 
foods,  drugs,  etc.  In  short,  the  health  authority  has  wide 
powers,  to  be  exercised  of  course  in  a  reasonable  manner, 
of  investigating  persons,  places  and  things. 

Then,  having  the  authority  of  sanitary  law  on  the  one 
hand  and  a  knowledge  of  certain  facts  on  the  other,  the 
board  of  health  proceeds  to  deliberation  as  to  what  action, 
if  any,  is  necessary  under  the  circumstances.  If  it  is 
decided  that  some  action  is  necessary  —  that  a  certain 
condition  should  be  remedied  —  then  the  next  step  is  to 
deal  with  the  person  (or  persons)  responsible  for  the  con- 


lO  A  MANUAL   FOR   HEALTH   OFFICERS 

dition.  Such  person  is  customarily  accorded  the  right  to 
be  heard  and  to  present  any  considerations  in  his  favor 
before  action  is  actually  taken. 

The  action,  when  taken,  may  consist  in  a  formal  notice, 
or  perhaps  simply  warning  or  advice.  Finally,  if  a  remedy 
can  be  effected  in  no  other  way,  legal  suit  may  be  instituted 
against  the  person  responsible  for  the  violation  of  the 
sanitary  law.^  The  board  of  health  rarely  takes  arbitrary 
action  into  its  own  hands  and  then  only  when  an  action  — 
e.g.,  the  abatement  of  a  nuisance  or  the  destruction  of 
infected  food  —  is  urgently  demanded  and  can  be  accom- 
plished in  no  other  way.  In  such  instance  there  must  be 
full  legal  power  and  a  perfectly  clear  case,  and  action  must 
be  strictly  in  accordance  with  legal  procedure.  Even  when 
disinfections  are  performed  by  the  authorities  the  theory 
is  that  this  is  merely  a  matter  of  convenience  and  effec- 
tiveness for  private  parties  who  would  otherwise  have  to 
attend  to  it  themselves  under  ofhcial  supervision.  Where 
specific  action  is  desired  the  object  of  the  sanitary  author- 
ities is  to  induce  that  action  on  the  part  of  private  persons 
rather  than  to  undertake  the  uncertain  proceeding  of 
themselves  intruding  into  private  affairs. 

An  order  of  the  board  of  health  (issued  usually  by  its 
health  officer)  is  a  notice  to  the  person  responsible  to  the 
effect  that  a  certain  condition  is  contrary  to  a  certain  san- 
itary ordinance  and  directing  that  person  to  take  action 
to  avoid  further  violation  of  the  law.  The  action  ordered 
may  be  to  improve  a  milk  supply,  to  alter  a  tenement,  or 
perhaps  simply  to  refrain  from  further  commission  of  an 
act  detrimental  to  the  public  health.  The  person  receiving 
the  notice  then  has  the  option:  either  to  comply  with  the 
order,  or  to  disregard  the  order  under  peril  of  proceedings 
by  the  board.  Such  proceedings  may  consist  in  a  suit 
instituted  by  the  board  to  recover  the  penalty  incurred,  or, 

1  Or  in  some  instances  as  a  preventive  measure  (through  injunction) 
in  advance  of  a  threatened  violation.     See  Part  II,  Chap.  6. 


LOCAL   ]\VA\;vn   AUTHORITIES  II 

in  extreme  cases,  the  board  itself  througli  its  agents  reme- 
dying the  condition  complained  of.  (For  further  details 
as  to  procedure  see  Part  II,  Chapters  6  and  7.)  In  a 
dispute  before  the  law  the  board  and  the  private  party 
have  equal  rights  to  be  heard  and  the  court  will  require 
the  board  to  prove  its  case  before  giving  judgment  in  its 
favor.  The  probable  attitude  of  a  court  of  law  toward  a 
given  question  should  therefore  always  be  borne  in  mind 
in  the  deliberations  of  board  and  health  ofificer. 

Special  Functions 

In  addition  to  the  fundamental  functions  already  out- 
Hned,  health  authorities  have  to  maintain  certain  functions 
of  an  auxiliary,  though  none  the  less  an  indispensable, 
nature.  Laboratory  service  for  bacteriological  diagnosis 
and  for  examination  of  food,  water,  etc.;  the  distribution 
and  perhaps  administration  of  antitoxins  and  vaccines; 
research  and  publicity  work;  the  registration  of  the  vital 
records  of  births,  marriages  and  deaths,  —  are  the  prin- 
cipal of  such  functions. 

Need  of  Executive  Staff 

Now,  how  are  all  these  functions  actually  to  be  exer- 
cised? The  board  of  health  obviously  cannot  as  a  body 
undertake  such  matters  as  the  inspection  of  many  different 
conditions  and  the  collection  of  the  data  necessary  for  wise 
decisions  on  technical  questions;  nor  can  it  intelligently 
consider  questions  of  medical  diagnosis,  sanitary  and 
diagnostic  bacteriology,  and  the  like.  The  board,  more- 
over, is  only  in  session  at  certain  times  and  there  is  a  great 
deal  of  business  to  be  handled  between  sessions.  Hence 
it  is  that  inspections  and  investigations,  routine  and  also 
many  matters  involving  discretionary  action  and  decision 
are  delegated  by  the  board  to  an  executive  staff  headed 
by  the  health  ofificer.  The  board  therefore  simply  directs 
in  a  general  manner,  leaving  discretion  in  execution  and 


12  A   MANUAL   FOR   HEALTH   OFFICERS 

detail  to  the  health  ofiicer  and  his  assistants  acting  on  the 
authorization  of  law  and  the  decisions  and  established 
policy  of  the  board. 

THE   STAFF 

The  Health  Officer,^  or  chief  sanitary  executive,  stands 
in  a  twofold  relation  to  the  board  of  health:  first,  as  expert 
adviser;  second,  as  executer  of  laws  and  orders.  In  other 
words,  his  duties  are: 

(i)  To  investigate  conditions; 

(2)  To  report  upon  them  to  the  board,  with  recommen- 
dations for  action;  and 

(3)  To  execute  (with  the  assistance  of  his  staff)  the 
specific  action  authorized  as  well  as  the  ordinary  activities 
of  the  health  department. 

The  position  of  the  health  officer  is  thus  analogous  to 
that  of  the  superintendent  of  schools,  of  police,  of  public 
works  —  in  short,  of  any  main  branch  of  the  municipal 
government.  In  Providence,  R.  I.,  he  is  in  fact  styled 
"  Superintendent  of  Health."  He  should  be  responsible 
to  the  board  of  health  directly  and  solely. 

Relation  to  the  Public 

In  his  relation  to  the  public  the  health  officer  stands 
as  the  representative  of  the  board  of  health.  Between 
sessions  of  the  board,  which  are  usually  infrequent,  he  is 
the  chief  sanitary  authority.  He  receives  the  complaints 
and  petitions  of  citizens  and  puts  in  effect  all  feasible 
remedies.  While  he  is  presumed  to  act  with  the  consent 
of  the  board,  if  not  by  its  orders,  administrative  efficiency 

1  The  health  officer  is  sometimes  known  by  other  titles:  as  "health 
commissioner"  (especially  in  the  larger  cities)  or  "health  inspector" 
(in  small  towns).  In  Massachusetts  he  is  designated  as  "agent  of  the 
board  of  health."  The  title  as  here  used  refers  to  the  chief  sanitary 
executive  of  the  local  board  of  health,  whether  he  act  alone  or  with 
assistance.  The  term  "sanitary  inspector"  is  reserved  for  subordi- 
nates to  the  health  officer. 


LOCAL   1 1  KALI  II   AUTHORITIES  1 3 

demands  that  within  tlic  law  wide  laLilude  be  allowed  him, 
not  only  in  matters  of  routine  and  detail,  hut  also  for 
action  in  emergencies.  In  many  instances  the  action  taken 
is  virtually  that  of  the  health  officer  alone,  though  such 
action,  to  be  valid,  must  be  either  preordained  or  at  any 
rate  ratified  by  the  board.  For  example,  Massachusetts 
statute  law'  provides  that: 

The  board  of  health  in  a  city  or  town  may  appoint  an  agent  or 
agents  to  act  for  it  in  cases  of  emergency  or  if  it  cannot  be  conveniently 
assembled;  and  any  such  agent  shall  have  all  the  authority  which 
the  board  appointing  him  had;  but  he  shall  in  each  case  report  his 
action  to  the  board  within  two  days  for  its  approval,  and  shall  be 
directly  responsible  to  it  and  under  its  direction  and  control. 

Relation  to  the  Board 

Such  a  relationship  should  be  established  between  the 
board  and  the  health  officer  that  when  the  latter  acts 
reasonably  and  in  accordance  with  the  ordinances  and  gen- 
eral policy  of  the  board  he  will  be  supported  by  it.  Thus, 
by  exercising  proper  discretion  the  health  officer  may 
wield  a  large  degree  of  power  without  exceeding  the  proper 
conduct  of  his  office.  The  degree  of  discretion  which  he 
may  properly  exercise  without  referring  matters  to  the 
board  for  action  will  depend  on  local  law  and  custom  and 
on  the  nature  of  the  individual  case.  He  should  not,  of 
course,  pass  beyond  at  least  a  general  authorization. 
There  should  be  at  once  effectiveness  of  action,  legal 
validity  of  action,  and  mutual  confidence  between  board 
and  health  officer. 

One  of  the  tendencies  in  public  health  organization  at 
the  present  time  is  to  concentrate  sanitary  powers,  to  give 
the  chief  executive  greater  power.  This  favors  efficiency-, 
provided  the  executive  is  still  subject  to  proper  checks.  As 
Lord  Bacon  says  in  his  essay  on  Dispatch:  "There  be 
three  parts  of  business;  the  preparation,  the  debate  or 
examination,  and  the  perfection.  Whereof,  if  }ou  look 
^  Revised  Laws,  Chap.  75,  Sec.  13. 


14  A  MANUAL   FOR   HEALTH  OFFICERS 

for  dispatch,  let  the  middle  only  be  the  work  of  many,  and 
the  first  and  last  the  work  of  few."  Such  a  tendency  is 
the  natural  development  of  more  highly  specialized  admin- 
istrative powers.  To  use  a  mechanical  analogy,  the 
health  officer  should  be  the  prime  mover,  and  his  staff  the 
auxiliary  machinery,  while  the  board  of  health  acts  as  a 
governor. 

Training  and  Qualifications 

The  position  of  health  officer  requires  both  technical 
and  administrative  ability.  The  two  are  distinct  and 
equally  important.  The  technical  school  graduate  who 
lacks  the  ability  to  put  his  scientific  knowledge  into  prac- 
tical effect  is  as  badly  off  as  the  man  of  mere  experience 
w'ho  knows  nothing  of  scientific  principles. 

Contrary  to  the  common  impression,  health  officers  need 
not  necessarily  be  physicians  —  though  a  medical  training 
is  highly  useful  —  and  there  is  now  some  trend  toward 
the  non-medical,  though  specially  trained,  health  official. 
Already  there  are  in  practice  able  health  officers  trained, 
not  in  medicine,  but  in  sanitary  biology  or  sanitary  engi- 
neering.^ 

The  tecJmical  training  necessary  to  health  officers  is 
best  obtained  in  a  school  having  a  special  department 
devoted  to  this  subject.  As  the  most  prominent  illustra- 
tion of  this  we  may  mention  the  School  of  Health  Officers 
recently  instituted  under  the  joint  management  of  Harvard 
University  and  the  Massachusetts  Institute  of  Technology, 
with  courses  in  all  the  branches  of  public  health  work.^ 

1  Knowles,  "Public  Health  Service  Not  a  Medical  Monopoly," 
and  Wells,  "A  Plea  for  a  More  General  Recognition  of  the  Qualifica- 
tions of  the  Sanitary  Engineer  for  Administrative  Public  Health  Work," 
Am.  Jour.  Pub.  Health,  1913,  vol.  HI,  no.  2. 

2  See  Whipple,  "  Public  Health  Education  "  (with  special  reference 
to  the  above  school),  address  before  N.  Y.  State  Conf.  San.  Officers, 
Science,  1914,  N.  S.,  vol.  XL,  p.  581.  A  number  of  medical  schools 
now  give  courses  leading  to  public  health  degrees. 


LOCAL  HEALTH  AUTHORITIES  15 

This  school  has  set  an  important  standard  in  estal^lishing 
for  its  graduates  a  certificate  of  public  health  (C.P.H.). 
It  is  open  to  all  properly  qualified  students,  medical  or 
non-medical;  a  college  or  technical  degree  is  a  preferred 
preparation  but  is  not  required  in  all  cases.  It  is  to  be 
hoped  that  courses  leading  to  similar  degrees  will  be  es- 
tablished in  many  universities,  on  at  least  the  level  of  the 
engineering  departments,  and  that  such  a  degree  or  certifi- 
cate from  a  reputable  institution  will  be  made  a  prerequisite 
for  the  practice  of  the  public  health  profession.  With 
wider  appreciation  of  the  importance  of  this  profession  to 
the  welfare  of  the  state,  no  doubt  such  a  desirable  condition 
of  affairs  will  be  brought  about,  and  the  remuneration  of 
expert  health  officers  will  become  adequate  to  induce  men 
to  prepare  themselves  in  the  manner  described.  For  those 
men  who  at  the  present  time  are  engaged  in  practice  as 
health  officers  or  desire  to  do  so  but  who  cannot  take  a 
regular  technical  course,  some  of  the  state  boards  of  health 
(e.g..  New  York  and  Kansas)  provide  short  courses  of 
instruction.  One  state  (New  Jersey)  requires  examina- 
tion and  licensing  of  health  officers  and  sanitary  inspectors 
but  makes  no  provision  for  the  instruction  necessary  to 
pass  the  examination.  Home  study  (as,  for  example,  of 
the  references  given  in  the  present  volume)  will  supply 
many  deficiencies;  every  health  officer  owes  it  to  himself 
and  his  community  to  maintain  and  keep  up  to  date  a  good 
though  not  necessarily  a  large  library  on  public  health, 
and  boards  of  health  should  make  appropriations  for  this 
purpose. 

The  administrative  qualifications  of  the  health  officer, 
important  though  they  are,  need  not  be  particularly  dis- 
cussed here.     Those  qualities  which  go  to  make  a  good 

executive  in  any  department  of  human  activity ability 

to  judge  circumstances,  to  formulate  a  plan,  and  through 
energy  tempered  with  tact  to  carry  that  plan  through 
to  a  successful  conclusion  —  are  likewise  here  demanded. 


1 6  A   MANUAL   FOR   HEALTH  OFFICERS 

Tact  is  particular!},-  required  in  the  liealth  officer  for  the 
reason  that  he  must  frequently  impose  acts  and  restric- 
tions which  are  disagreeable  to  those  who  are  the  subjects 
of  them.  His  quarantines  may  be  against  unreasoned 
opposition  and  the  health  regulations  may  be  regarded  as 
arbitrary  afflictions;  to  the  property  owner  he  may  appear 
as  the  instigator  of  unnecessary  expenditure  and  to  the 
householder  as  an  uncalled-for  disturber  of  comfortable  — 
but  objectionable  —  habit.  Such  police  work  is  more 
readily  managed  in  many  cases,  as  every  successful  health 
officer  knows,  by  tactful  persuasion  than  by  legal  measures. 
In  other  words  the  average  man  can  be  convinced  without 
much  difficulty  that  to  obey  regulations  is  his  only  prudent 
course.  But  tact,  of  course,  means  more  than  this.  It 
means  knowing  where  to  go  strongly  and  where  to  go 
softly;  where  to  use  persuasion  and  also  where,  in  the 
residuum  of  difficult  cases,  to  use  compulsion.  And  all 
this  must  be  done  without  losing  direction  and  momentum 
in  the  well-defined  general  campaign  which  every  health 
officer  should  constantly  be  carrying  on. 

Nature  of  Work 

In  small  communities  the  health  officer  perhaps  works 
single-handed,  performing  all  the  executive  work  of  the 
board  of  health.  Even  very  small  places,  however,  some- 
times divide  duties  between  a  "  health  officer,"  a  physician 
who  attends  to  the  direction  of  the  work  and  to  medical 
and  bacteriological  matters,  and  an  "  inspector,"  his 
assistant,  who  carries  on  the  routine  work  of  inspections, 
disinfection,  etc.  In  the  larger  places  the  health  officer 
has  several  assistants  who  relieve  him  of  the  detail  and 
routine  work  which  can  be  done  cheaply  and  effectively, 
under  his  direction,  by  inspectors,  clerks,  analysts,  etc., 
leaving  him  free  for  the  larger  responsibilities  of  expert 
direction. 


LOCAL   JIKAL'I'JI   AU'I'U()RI'rii:s  17 

The  various  special  classes  of  service  rcciuircd  in  tlie 
health  department  staff  are  as  follows: 

I.  Inspection  Service.  —  Inspectors  should  be  trained 
men  having  a  fundamental  knowledge  of  sanitary  principles, 
though  of  course  not  nearly  so  extensive  a  training  as  the 
health  officer.  Milk  inspectors  and  other  special  employees 
should  in  addition  be  specially  qualified.  Aside  from  the 
technical  knowledge  of  the  duties  of  his  position  tlie  in- 
spector should  possess  dignity  and  tact.  He  must  be 
neither  overbearing  nor,  on  the  other  hand,  lenient,  neither 
talkative  nor  yet  taciturn.  His  words  and  actions  are 
taken  by  most  persons  to  be  the  direct  and  authoritative 
expression  of  the  department,  and  should  be  accordingly 
guarded. 

Tact  in  the  inspector  involves  courtesy  and  common- 
sense.  The  two  extremes  are  to  be  avoided :  the  inspector 
who  threatens  and  he  who  may  be  persuaded  or  deceived 
into  passing  over  improper  conditions.  In  cases  of  doubt 
the  inspector  should  not  use  discretion  —  dangerous  in  a 
subordinate  —  but  should  suspend  judgment,  preserve 
silence,  and  report  the  matter  to  the  "  ofhce  "  for  decision. 

The  inspector,  aside  from  disinfection  duties  and  the 
like,  has  two  functions:  to  report  on  conditions  to  the  health 
officer,  and  to  bear  notices  and  other  communications  from 
the  health  officer  to  private  persons.  No  opinion  should 
be  expressed  by  inspectors  as  to  the  probable  action  of  the 
office  nor  comment  be  made  on  such  action  as  may  have 
been  taken.  All  important  communications  to  individ- 
uals should  be  made  in  writing  and  from  the  office.  Com- 
plaints of  an  important  nature  should  not  be  received 
by  inspectors  but  should  be  made  directly  to  the  health 
officer,  preferably  in  writing.  Of  course  such  rigid  rules 
do  not  apply  to  trivial  matters  which  may  be  set  right  by 
a  simple  oral  notification  by  the  inspector,  and  such  noti- 
fications should  be  recognized  as  a  regular  part  of  routine. 
There  are  instances  in  which  a  mere  visit  of  the  inspector 


l8  A   MANUAL   VOR   HEALTH  OFFICERS 

will  be  sufficiently  impressive  to  produce  the  desired  action, 
and  in  such  cases  formalities  arc  superfluous.  Inspectors 
should  thus  discriminate,  though  acting  on  the  safe  side 
in  doubtful  cases. 

The  common  fault  of  inexperienced  inspectors  is  to  miss 
violations  and  to  exaggerate  those  which  they  do  find; 
the  fault  of  old  inspectors,  on  the  other  hand,  is  to  grow 
lax  in  judgment  through  becoming  accustomed  to  con- 
ditions. To  prevent  the  latter  condition  it  may  be  desir- 
able to  shift  inspectors  to  new  districts  at  not  too  frequent 
intervals. 

Full-time  inspectors  should  as  a  rule  wear  uniforms, 
which  are  a  distinct  advantage  in  impressing  certain  classes 
of  people;  for  part-time  men  a  badge  may  be  sufficient. 

2.  Medical  Service.  —  The  board  of  health  must  have  an 
official  medical  representative.  His  duty  consists  very 
largely  in  making  diagnoses  in  doubtful  or  suspected  cases 
of  communicable  disease  and  in  determining  whether  or 
not  cases  are  ready  for  release  from  quarantine.  Occa- 
sionally also  the  "  medical  inspector  "  or  "  board  of  health 
physician,"  as  he  may  be  called,  may  be  required  to  admin- 
ister antitoxin  or  perform  vaccinations. 

Health  authorities  practically  always  have  the  right  to 
investigate  doubtful  or  suspected  cases  of  communicable 
disease.  Thus  when  there  are  well-founded  rumors  that 
an  unreported  case  of  communicable  disease  exists,  when 
there  are  "  contacts  "  to  be  examined  or  kept  under  sur- 
veillance, or  when  two  or  more  physicians  disagree  as  to 
the  nature  of  a  case,  it  is  the  duty  of  the  board  of  health 
to  detail  its  medical  representative  to  make  an  inspection 
and  decision.  It  may  also  be  desirable  to  subject  to  con- 
firmation the  report  of  the  private  physician  that  his  case 
is  ready  for  release  from  quarantine.  And  other  ques- 
tions of  a  similar  nature  may  arise. 

If  the  health  officer  is  a  medical  man  he  may  naturally 
perform  the  duties  of  medical  inspector;    if  he  is  not,  a 


LOCAL  HEALTH  AUTHORITIES  I9 

physician,  who  may  or  may  not;  be  a  member  of  t,he  board, 
should  be  designated  to  perform  this  function.  His  jjosi- 
tion,  especially  when  called  upon  to  decide  between  the 
conflicting  opinions  of  other  practitioners,  requires  author- 
ity tempered  with  tact.  The  board  physician  may  be 
retained  at  a  fixed  salary,  or,  as  seems  preferable,  may 
receive  a  stipulated  fee  for  each  visit. 

The  medical  inspector  of  the  board  of  health  should  not 
be  confused  with  the  "  city  "  or  "  poor  "  physician.  The 
latter  is  an  official  of  the  city  government  whose  duty 
is  the  treatment  of  indigent  patients,  and  he  is  usually 
accountable  to  some  municipal  body  other  than  the  board 
of  health.  In  such  a  case  it  does  not  seem  desirable, 
although  possible,  that  he  act  as  medical  inspector  for 
the  board;  the  functions  are  quite  distinct  and  there 
may  arise  embarrassment  in  following  decisions  rendered 
by  an  officer  not  subject  to  the  board's  appointment. 

3.  Public  Health  Nurse.  —  A  comparatively  new  member 
of  the  modern  board  of  health  staff  is  the  public  health 
nurse.  It  is  now  recognized  by  progressive  authorities 
that  sanitary  policing,  with  its  distinct  limitations,  is  not 
the  whole  of  their  duty.  Even  under  the  best  environ- 
mental conditions  obtainable  by  that  method  there  remain 
ignorance  and  home  conditions  springing  from  it  which 
are  a  constant  detriment  to  the  public  health.  This  fact 
was  first  recognized  in  the  tuberculosis  campaign,  and, 
later,  in  the  campaign  against  infant  mortality.  Tuber- 
culosis patient  and  mother  respectively  were  sadly  in  need 
of  instruction  in  home  and  personal  hygiene,  and  such 
instruction  was  seen  to  be  the  most  powerful  single  weapon 
that  could  be  brought  to  bear  against  the  twin  evils. 
Hence  the  institution  of  the  public  health  nurse. 

The  first  duty  of  the  public  health  nurse  is  advice  and 
instruction,  with  the  object  of  prophylaxis  in  the  individual 
case:  instruction  to  the  mother  in  the  care  of  her  child 
and  to  the  tuberculosis  patient  in  a  proper  regime  and  the 


20  A  MANUAL   FOR   HEALTH  OFFICERS 

avoidance  of  spreading  infection.  Such  instruction  should 
be  not  merely  pedantic,  but  should  be  combined  with  en- 
couragement and  assistance,  the  latter  to  take  the  form 
of  keeping  the  patient  in  touch  with  charitable  agencies, 
making  hospital  arrangements,  and  the  like.  She  may 
also  perform  a  limited  amount  of  incidental  minor  nursing 
work,  which  should  be  of  great  assistance  in  gaining  con- 
fidence and  impressing  her  instructions.^  Finally,  she 
should  perform  incidental  inspection,  noting  conditions 
which  she  may  refer  to  the  sanitary  inspectors;  thus  she 
may  readily  note  matters  connected  with  housing,  the 
keeping  of  quarantine  (though  she  does  not  ordinarily  enter 
quarantined  families),  and  the  like. 

The  public  health  nurse  should  be  a  trained  nurse,  pref- 
erably with  a  social  service  training  such  as  is  now  pro- 
vided in  connection  with  some  hospitals,  dispensaries  and 
social  settlements.  The  phases  of  her  work  will  be  brought 
out  later  under  the  heads  of  Tuberculosis  and  Child  Hy- 
giene. 

In  the  work  of  the  pubKc  health  nurse  the  health  author- 
ities extend  their  activity  beyond  the  region  of  strictly 
public  hygiene  into  that  of  personal  hygiene.  Such  ex- 
tension may  be  justified  as  demanded  by  the  urgent  need 
of  attacking  in  their  very  strongholds  the  great  public 
health  problen-.s  of  tuberculosis  and  infant  mortality. 
Sanitary  policing  is  of  little  value  so  long  as  uninstructed 
and  unsupervised  consumptives  spread  germs  in  their 
families  and  among  their  associates  in  a  way  beyond  such 
policing.     The   majority   of   tuberculosis   patients  cannot 

^  The  public  health  nurse  should  be  distinguished  from  the  "dis- 
trict" or  "visiting"  nurses,  maintained  by  charitable  societies,  whose 
work  consists  almost  entirely  in  nursing  care.  The  public  health 
nurse  should  maintain  constant  cooperation  with  such  nurses  and 
refer  to  them  any  of  her  cases  which  need  special  nursing  attention. 
See  Waters,  "Visiting  Nursing  in  the  United  States"  (Charities  Pub- 
lication Committee,  105  East  22nd  St.,  New  York  City),  which  treats 
of  both  classes  of  work. 


LOCAL  HEALTH  AUTHORITIES  21 

and  need  not  be  confined  in  hospitals;  hence  their  home 
life  must  be  regulated  through  pro])er  training.  Again, 
regulation  of  milk  supplies  is  only  a  partial  measure  of 
control  of  infant  morbidity  and  mortality,  and  should  be 
supplemented  by  instruction  of  mothers  to  the  end  that 
they  may  properly  regulate  the  equally  important  matters 
of  feeding,  clothing  and  other  care  of  the  infant  and  the 
ventilation  and  cleanliness  of  the  home.  There  is  such  a 
widespread  need  of  such  instruction  and  such  beneficial 
economic  and  social  results  follow  it  that  it  may  well  be 
made  public.  Both  of  these  lines  of  attack,  through  the 
public  health  nurse,  were  first  taken  up  by  private  organ- 
izations —  against  tuberculosis  some  years  ago,  against 
infant  mortality  more  recently  —  and  now  that  their 
feasibility  as  public  health  measures  has  been  demonstrated 
they  are  due  to  be  taken  over  by  the  public  authorities.^ 
When  this  is  done  the  idea  of  charity  should  be  excluded. 
4.  Laboratory  Service.  —  Every  board  of  health  requires 
laboratory  service,  and  the  laboratory  should  be  near  at 
hand.  If  it  is  necessary  to  send  samples  of  milk  and  water 
and  diagnostic  specimens  to  a  state  laboratory  at  a  dis- 
tance, there  are  necessarily  inconveniences,  disadvantages 
and  even  inaccuracies  involved.  The  importance  of 
prompt  reports  on  diphtheria  cultures,  for  example,  is 
obvious.  Laboratory  work  may  wholly  or  in  part  be 
performed  by  the  health  officer,  or  it  may  be  performed  by 

^  Even  where  the  health  authorities  cannot  as  yet  command  the 
funds  to  maintain  one  or  more  public  health  nurses,  they  may,  by 
conferring  upon  those  privatelj'  maintained,  the  appointment  of  special 
inspector,  with  right  to  wear  a  badge,  give  them  a  valuable  prestige 
and  secure  closer  cooperation.  Where  this  has  been  done  it  has  proved 
a  practical  preliminary  to  assuming  public  maintenance  of  the  nurse. 
In  such  a  case  the  nurse  acts  only  incidentally  as  inspector,  so  that 
practically  the  health  authorities  do  not  assume  to  control  her  gen- 
eral activities  and  there  need  be  no  conflict  on  that  point.  It  scarcely 
needs  be  said  that  the  private  organization  employing  the  nurse  must 
be  convinced  of  the  desirability  of  this  step  and  should  make  formal 
application  for  it. 


22  A  MANUAL  FOR  HEALTH  OFFICERS 

a  private  bacteriologist  by  special  arrangement,  but  in 
places  where  there  is  any  great  amount  of  it  a  bacteriologist 
and  chemist  should  be  employed.  Some  points  in  con- 
nection with  small  board  of  health  laboratories  are  taken 
up  in  Appendix  D. 

5.  Veterinary  Service.  —  In  connection  with  supervision 
of  milk  supplies  and  of  slaughtering,  and  in  the  control  of 
communicable  diseases  among  animals,  the  board  of  health 
may  appoint  its  own  veterinarian.  Examinations  of  dairy 
cattle  by  the  official  veterinarian  are  more  satisfactory  than 
the  reports  of  private  veterinarians,  though  the  former  plan 
may  mean  a  considerable  expense  to  the  health  department. 

6.  Labor.  —  The  board  of  health  requires  a  certain 
amount  of  service  in  the  shape  of  labor,  clerical  and  manual, 
more  or  less  expert.  This  head  includes  office  clerks;  also 
laborers  who  may  be  employed  in  abatement  of  mosquito- 
breeding  places,  and  the  like. 

7.  Legal  Counsel  and  Service.  —  Law,  next  to  sanitation, 
is  the  subject  on  which  the  board  most  frequently  requires 
expert  advice  and  service.  The  board  usually  apjxjints, 
therefore,  a  counsel  or  attorney.  His  duties  consist  in 
giving  advice  on  all  sorts  of  legal  questions,  the  criticism 
and  drafting  of  ordinances,  resolutions  and  forms,  and 
the  trying  of  cases.  He  stands  outside  of  the  regular 
organization  of  the  staff,  and  is  commonly  employed  on  a 
salary  rather  than  a  fee  system.  Frequently  this  work 
is  taken  care  of  by  the  regular  town  or  city  attorney, 
though  some  boards  appoint  their  own  counsel.  Though 
he  should  not  be  a  member  of  the  board,  the  presence  of 
the  counsel  at  board  meetings  is  indispensable. 

Aside  from  counsel,  it  is  essential  that  the  health  officer 
himself  have  a  thorough  understanding  of  the  main  prin- 
ciples of  the  sanitary  law  and  of  the  state  and  local  laws 
under  which  he  must  work.  Some  of  the  legal  principles 
underlying  board  of  health  work  are  discussed  in  Part  II, 
Chapter  7. 


l.OCAI.   UKMJVil   AU'lHOkrTIES  23 

The  office  of  the  board  of  health  should  he  eoiidiKhd 
like  any  well-ordered  business  offiee.  It  should  be  readily 
accessible  to  the  public  and  convenient  office-hours  should 
be  kept,  provision  being  made  for  receiving  bacteriological 
specimens  at  all  reasonable  hours  —  say  until  5  p.m.  or 
even  later.  In  the  larger  towns  a  clerk  should  be  employed 
to  take  charge  of  the  office  while  the  health  officer  is  out, 
and  to  answer  questions,  receive  telephone  calls,  issue  per- 
mits and  attend  to  the  general  routine.  The  office  should 
be  open  for  one  or  two  stated  hours  on  Sundays  and  holi- 
days. In  order  to  attend  promptly  to  communicable 
disease  and  to  receive  instructions,  sanitary  inspectors 
should  report  to  the  office  at  appointed  hours,  say  at 
8  a.m.,  I  p.m.  and  4.30  p.m.  Modern  recording  devices 
should  be  installed,  e.g.,  card  catalogs  for  shifting  records 
and  indexes.  On  account  of  the  possibility  of  misplacing 
cards,  book  records  are  probably  superior  for  permanent 
serial  records,  such  as  those  of  births,  marriages  and  deaths 
and  communicable  disease.  All  such  records  should  be 
kept  in  safes  or  vaults.  Notices  and  letters  should  be 
typewritten  and  duplicates  kept  on  file.  An  office  rail 
for  the  separation  of  visitors  is  a  desirable  feature. 

The  health  officer's  library  should  include  such  standard 
works  as  are  referred  to  in  the  present  volume,  and  should 
be  kept  quite  up  to  date  by  the  purchase  of  new  and 
authoritative  volumes.  Among  periodicals  the  American 
Journal  of  Public  Health^  is  indispensable;  current  num- 
bers and  bound  volumes  of  previous  years  should  be  kept 
for  reference.  Bulletins  published  by  various  state  and 
municipal  departments  of  health  may  ordinarily  be  ob- 
tained regularly  on  application,  as  well  as  several  of  the 
Federal  publications  —  e.g.,  the  Public  Health  Reports, 
Bulletins  of  the  Hygienic  Laboratory,  monthly  list  of  the 
Department  of  Agriculture  publications,  etc. 

1  See  p.  98. 


24  A   MANUAL   FOR   HEALTH  OFFICERS 

THE   NATURE    OF   SANITARY   AUTHORITY 

The  supervision  of  tiic  public  health  is  based  on  the  gen- 
eral police  power  of  the  state,  using  both  terms  in  their 
broadest  sense.  That  power  involves  the  right  of  the 
state  to  regulate  the  conduct  of  citizens  in  such  a  way  that 
their  acts  or  omissions  do  not  materially  and  unreasonably 
injure  other  citizens.  As  society  grows  more  complex  the 
exercise  of  that  power  involves  more  extended  functions. 
Most  of  these  are  prohibitive  in  character,  though  some 
of  the  auxiliary  functions,  such  as  publicity  work  and 
the  establishment  of  dispensaries  and  hospitals,  are  con- 
structive. The  latter  have  been  fostered  by  the  growing 
cooperation  of  health  departments  with  organized  char- 
ities and  other  social  service  organizations. 

The  sovereign  power  of  the  state,  as  expressed  through 
legislature,  delegates  sanitary  functions  to  certain  official 
bodies  and  individuals  —  commonly  to  boards  of  health 
—  who  thus  obtain  their  powers  through  statute  law. 
That  law  is  presumed  to  represent  the  kind  and  degree 
of  authority  which  the  people  at  any  time  desire  to  confer 
on  their  servants  in  sanitary  administration.  It  is  neces- 
sarily granted  in  general  terms  which  are  subject  to  inter- 
pretation by  the  courts. 

Sanitary  Powers  and  their  Definition.  —  From  time 
immemorial  powers  of  an  extraordinary  and  sweeping 
character  have  been  reposed  in  sanitary  authorities.  The 
arbitrary  and  summary  power  to  deprive  persons  of  lib- 
erty and  property,  to  check  wholly  or  partly  commercial 
operations,  and  to  disturb  civic  life  to  any  extent  deemed 
necessary  to  avert  menaces  to  public  health,  has  in  the 
past  been  commonly  conferred  upon  them.  The  Courts, 
in  reviewing  their  acts,  have  usually  given  them  the  benefit 
of  the  doubt  if  there  was  any  defensible  ground  for  the  ex- 
ercise of  those  large  powers.  The  following  opinion  exem- 
plifies the  traditional  attitude  of  the  Courts  towards  them: 


LOCAL   HEALTH   AUTHORITIES  25 

Their  action  is  intended  to  be  prompt  and  summary.  They  are 
clothed  with  extraordinary  powers  for  the  protection  oi  the  commu- 
nity. .  .  and  it  is  imjjortant  that  their  proceedings  should  be  delayed 
as  little  as  possible.  Delay  might  defeat  all  beneficial  results;  the 
necessity  of  the  case,  and  the  importance  of  the  public  interests  at 
stake,  justify  prom[)t  action.^ 

Such  powers  were  from  the  beginning  based  upon  public 
fear  in  the  face  of  epidemic  disease.  It  has  been  said  by 
Kiphng  that  a  doctor  can  by  raising  a  red  cross  in  a  desert 
turn  it  into  a  center  of  population,  and  by  hoisting  a 
yellow  flag  in  a  center  of  population  turn  it  into  a  desert. 

That  far-reaching  powers  are  still  conceded  to  sanitary 
authorities  is  indicated  by  the  opinion  (more  recent  than 
that  just  quoted)  handed  down  in  the  Montclair  (N.  J.) 
tuberculin-test  case.  In  this  opinion  the  Court  said  that 
"If  the  life  of  one  cliild  is  endangered  by  the  possible 
communication  of  tuberculosis  through  cows'  milk  extreme 
prudence  may  be  proper  "  in  the  regulation  of  the  milk 
supply  .2 

Definition  of  Sanitary  Powers 

There  is,  however,  at  the  present  time  a  clear  tendency 
to  define  the  powers  of  health  authorities  more  exactly 
and  to  confine  them  within  closer  ordinary  limits.  This 
is  the  logical  sequel  of  a  more  exact  sanitary  science. 
In  the  process  of  legal  definition  the  sanitary  functions 
have,  it  is  true,  in  some  instances  been  extended,  but  more 
often  they  have  been  curtailed.  This  more  critical  atti- 
tude of  the  courts  has  recently  been  exemplified  in  the 
"  dip  milk  ".  decision  of  the  Supreme  Judicial  Court  of 
Massachusetts,  by  which  the  power  of  a  local  board  of 
health  in  that  state  to  make  and  enforce  a  regulation  for- 
bidding the  sale  of  "  dip  "  or  "  loose  "  milk  was  denied. 
The  Court  ruled   that  the  general  statute  under  which 

^  Opinion  by  Justice  Wells  in  Salem  v.  Eastern  R.  R.  Co.,  98  Mass. 
431  >  433;   quoted  in  Massachusetts  Manual  for  Boards  of  Health,  1899. 
2  See  Appendix  C. 


26  A   MANUAL  FOR  HE,\LTH  OFFICERS 

the  board  of  health  assumed  to  act  was  not  broad  enough 
to  give  the  authority  in  question.  "  This  statute,"  reads 
the  opinion,  "  does  not  give  the  board  power  to  make  regu- 
lations as  to  all  matters  affecting  the  public  health,  .  .  . 
Milk  kept  in  a  \cssel,  as  this  was  ke]")t  1)\-  the  defendant, 
was  not  a  '  nuisance,  source  of  fillli,  or  cause  of  sickness,' 
which  gave  the  board  of  health  jurisdiction  to  take  any 
action  or  make  any  regulation  under  the  [statute] . "  ^  Thus, 
although  the  powers  conferred  by  the  statute  were  very 
general  a  strict  interpretation  was  placed  upon  them  by 
the  Court.  Not  many  years  ago  the  right  of  a  board  of 
health  to  dictate  such  a  rule  under  such  general  powers 
would  doubtless  have  gone  unquestioned  in  the  courts. 

Other  examples  of  the  critical  spirit  of  legislatures  and 
courts  are  not  far  to  seek.  Laws  are  much  more  specific 
than  formerly  and  more  frequently  mandatory,  rather  than 
merely  permissive.  The  reserve  powers  of  sanitary  author- 
ities formerly  much  exceeded  their  duties;  now  powers 
and  duties  come  nearer  to  coinciding.  To  get  things  done 
it  is  found  necessary  to  define  them  and  assign  them  defi- 
nitely to  certain  authorities.  The  precise  terms  and  wide 
scope  of  the  state  and  federal  "  pure  food  "  laws  are  an 
instance  in  point.  If  the  problem  is  quantitative  it  is 
becoming  more  common  to  establish  exact  legal  standards, 
both  to  facilitate  administration  and  to  limit  the  exercise 
of  authority.  Courts  now  call  for  expert  testimony  and 
discuss  fine  quantitative  points,  as  in  the  well-known 
Chicago  Drainage  Canal  case,  in  which  the  question  was 

'  Com.  V.  Drew,  Opinion  dated  April  4,  191 1,  quoted  in  The  Banker 
a7id  Tradesman,  Boston,  vol.  43,  no.  16,  p.  921;  cf.  Jour.  Am.  Pub. 
Health  Assn.,  191 1,  vol.  I,  no.  6,  p.  466;  also  discussion  by  Jordan, 
Am.  Jour.  Pub.  Health,  1912,  vol.  II,  no.  2.  A  similar  decision  was 
later  handed  down  by  the  Superior  Criminal  Court  of  Massachusetts 
in  regard  to  a  rule  requiring  that  fruit  exposed  for  sale  be  protected 
from  contamination  by  dust.  To  obviate  the  barrier  raised  by  the 
"  dip  milk  "  decision,  a  statute  has  since  (in  1912)  been  adopted  by  the 
Massachusetts  Legislature. 


LOCAL    IIKAL'rn   AUTHOR riFLS  27 

to  decide  jusL  liow  luinnful  sewage  from  llie  city  oi  ("liicago, 
discharged  into  the  Mississippi  River,  was  to  the  citizens 
of  St.  Louis  who  used  the  waters  of  the  latter  for  drinking 
purposes. 

All  of  this  indicates  that  henceforth  boards  of  health 
must  be  prepared  to  show  due  and  full  cause  for  the  meas- 
ures which  they  take.  At  the  same  time,  as  the  court 
remarked  in  the  Montclair  tuberculin-test  case,  "  the  action 
of  a  local  board  in  adopting  measures  for  the  protection  of 
public  health  will  not  be  set  aside  by  the  Court  if  the  board 
has  acted  reasonably  upon  evidence  that  might  satisfy  a 
reasonable  man."  A  certain  degree  of  discretion  (e.g.,  for 
emergencies)  must  clearly  be  allowed  to  sanitary  authorities, 
and  the  organic  public  health  law,  as  interpreted  by  the 
courts,  is  usually  capable  of  flexible  application  in  the  fram- 
ing of  ordinances.  The  Courts  simply  require  that  such 
application  be  demonstrably  justifiable  and  reasonable 
within  the  general  powers  conferred  by  statute. 

ADMINISTRATION 

Efficiency  in  Local  Work.  —  This  is  not  the  place  to 
discuss  the  necessity  of  keeping  public  health  work  entirely 
free  from  harmful  political  influences,  of  obtaining  and 
keeping  efficient  sanitary  officers,  and  the  like.  Merit 
systems  of  employment  and  the  consideration  of  budgets 
entirely  on  their  merits  (movements  which  are  fortunately 
gaining  ground)  are  matters  of  the  larger  question  of 
municipal  government  as  a  whole.  Something,  however, 
may  be  said  as  to  appropriations  and  the  ways  of  using 
them. 

The  majority  of  boards  of  health  in  this  country  are 
working  on  appropriations  much  smaller  than  thorough 
public  health  work  calls  for.  But  even  so  the  question 
may  be  asked,  whether  the  majority'  of  departments  are 
employing  even  the  limited  funds  they  have  to  the  best 


28  A   MANUAL    FOR    IIKALTII   OFFICERS 

advantage.  For  until  they  can  demonstrate  that  they  are, 
they  must  be  judged  in  some  degree  unworthy  of  the  trust 
implied  in  greater  appropriations. 

It  may  be  premised  at  once  that  the  way  to  spend  a 
small  appropriation  is  not  to  spread  it  out  thin  over  the 
whole  possible  field  of  endeavor,  but  to  concentrate  upon  a 
very  few  specific  problems  and  those  of  greatest  local 
importance.  Only  in  this  way  can  results  be  obtained  and 
demonstrated  as  the  basis  for  further  demands  upon  the 
public  confidence  and  the  city  treasury.  But  such  work 
must  be  persistent  as  well  as  concentrated.  Too  many 
boards  of  health  either  range  in  a  desultory  way  over  a 
scattered  and  unsystematized  field,  or  else,  while  usually 
limiting  their  activities  to  the  necessities  forced  upon 
them,  they  arise  at  intervals  to  spasmodic  and  spectacular 
"  campaigns  "  such  as  "  swat  the  fly,"  "  clean-up,"  and 
whatnot.  Such  an  "  outburst  method  "  may  have  some 
transient  results,  which,  however,  very  quickly  die  out 
unless  sustained  by  continued  and  systematic  adminis- 
trative effort. 

The  dangers  of  exaggeration  are  to  be  guarded  against. 
Health  officers  can  be  impressive  in  their  statements, 
reports  and  appeals  without  departing  from  the  truth, 
which  is  frequently  quite  as  striking  as  need  be.  Exag- 
gerated promises  lead  to  work  for  the  sake  of  superficial 
results  or  to  practice  w^hich  is  "  ultra  vires  "  —  that  is,  ex- 
ceeding legal  powers;  while  exaggerated  reports  of  results 
achieved  assumes  undue  responsibility  for  the  health 
authorities  and  w^eakens  subsequent  requests  for  funds 
for  w^ork  still  needed.  Public  health  programs  cannot 
be  accomplished  in  a  day,  and,  once  a  proper  basis  is  estab- 
lished, steady  progress  recorded  in  accurate  reports  is  the 
only  legitimate  aim. 

The  Problems  of  Small  Communities.  —  Many  small 
communities  have  a  peculiar  problem  in  that  they  cannot 
afford  to  employ  an  expert,  full-time  health  officer  and  to 


LOCAL  ni;Ai;rrf  AuriioRiriKS  29 

maintain  the  organization  necessary  for  thoroii^^l)  jjiihlic: 
health  work.  Such  communities  have  tf)  depend  iipfjti  a 
busy  practitioner,  whose  chief  interest  is  in  mecHcal  prac- 
tice, for  part  of  his  time,  with  perhaps  an  inexpert  assistant. 
Laboratory  work  is  minimized  and,  it  may  be,  sent  to  a 
distant  state  laboratory.  It  is  true  that  some  part-time 
health  officers  with  limited  means  for  organization  do 
overcome  the  disadvantages  and  render  conscientious  and 
effective  service  to  their  communities,  but  in  many  such 
instances  it  is  impossible  to  obtain  adequate  service  in 
this  way. 

To  meet  such  a  situation  the  plan  of  jomt  sanitary  ad- 
ministration has  been  proposed.  Under  this  plan  several 
contiguous  communities,  too  small  to  afford  expert  health 
service,  unite  in  the  employment  of  a  trained  health  officer 
and  the  maintenance  of  a  joint  health  office.  Thus  can  be 
secured  the  services  of  a  full-time  competent  and  properly 
salaried  officer  who  combines  and  systematizes  the  work 
of  the  various  communities  in  such  a  way  as  to  give  them 
adequate  service  with  little  or  no  increase  in  appropria- 
tions, or  at  any  rate  at  the  lowest  economical  cost.  A 
joint  laboratory  would  be  maintained,  with  a  bacteriologist 
whose  concentrated  expert  services  would  be  preferable  to 
the  scattered  private  examinations  which  would  otherwise 
be  necessary.  There  would  be  either  joint  inspectors,  or, 
if  preferred,  local  inspectors  directed  by  the  joint  execu- 
tive. It  is  interesting  to  note,  in  passing,  that  the  same 
principle  has  been  widely  applied,  with  success,  in  another 
field  —  that  of  education  —  in  the  consolidation  of  rural 
schools,  by  which  all  the  schools  in  a  district  are  placed 
under  a  single  superintendent  and  system  maintained  and 
controlled  jointly  by  the  communities  concerned.  Coop- 
erative public  health  administration  is  one  of  the  most 
important  of  modern  developments,  and  promises  to  solve 
the  problem  of  efficient  but  economical  service  for  all 
small    communities   which    can    and    will    join    forces  for 


30  A  MANUAL   FOR   HEALTH  OFFICERS 

mutual   benefit.^      Of  the  problem  of  the  more  rural  dis- 
tricts something  will  be  said  in  the  following  chapter. 

REFERENCES 

Reports  of  the  Committee  of  the  American  Public  Health  Associa- 
tion on  Organization  and  Functions  of  Municipal  Health  Depart- 
ments, published  in  Am.  Jour.  Pub.  Health,  1912  and  following  years. 

Blanchard,  "Modern  Board  of  Health  Methods  in  a  Small  Town," 
and  Gunn,  "Modern  Board  of  Health  Methods  in  Small  Cities," 
Jour.  Am.  Pub.  Health  Assn.,  1911,  vol.  I,  no.  5,  pp.  369,  373. 

*  Such  apian  is  in  effect  at  the  present  time  at  Wellcsley,  Mass.,  in- 
cluding several  of  the  neighboring  towns.  It  was  outlined  in  a  paper 
by  E.  B.  Phelps,  "An  Experiment  in  Public  Health  Administration," 
Am.  Jour.  Pub.  Health,  1913,  vol.  HI,  no.  9,  and  is  reported  upon  in 
full  by  him  in  Public  Health  Rpts.,  Sept.  25,  1914,  vol.  XXIX,  no.  39. 
For  a  summary  of  this  important  work  see  Appendix  F  of  the  present 
volume.  A  certain  degree  of  cooperation  on  a  similar  principle  has  also 
been  established  between  the  Board  of  Health  of  Montclair,  N.  J.,  and 
some  neighboring  small  towns.  At  Wilmington,  N.  C,  a  consolidation 
of  city  and  county  boards  of  health  has  been  effected. 


CHAPTER   II 
STATE    HEALTH    AUTHORITIES 

Just  as  local  health  authorities  care  for  public  health 
among  the  individuals  which  compose  the  local  community, 
so  state  authorities  exert  power  in  those  matters  which 
are  common  to  communities  throughout  the  state.  State 
health  departments  represent  a  later  form  of  organization 
than  the  local,  having  been  called  into  existence  by  the 
natural  development  of  sanitary  questions  of  state-wide 
import. 

Originally,  as  shown  by  the  creative  statute  of  Massa- 
chusetts (which  had  the  first  state  board  in  the  United 
States),  the  functions  of  the  state  board  were  entirely 
advisory  in  character;  the  board  was  to  "  make  investi- 
gations," "  gather  information  for  diffusion  among  the 
people,"  and  make  "  suggestions  as  to  legislative  action." 
This  is  still,  perhaps,  the  most  important  function  of  state 
boards  of  health.  But  of  recent  years  there  have  been 
added,  according  to  the  exigencies  of  state-wide  action, 
certain  functions  of  an  executive  nature.  These  are  exem- 
plified in  supervision  of  foods  and  drugs,  of  water-supplies, 
and  of  sewage  disposal,  and  in  the  comprehensive  registra- 
tion of  vital  statistics.  And  the  executive  sphere  of  state 
action  will  doubtless  continue  to  increase. 

On  the  other  hand  limitations  and  conservative  policies 
restrain  state  health  authorities  from  interfering  in  matters 
which  can  be  dealt  with  by  the  local  authority,  except 
when  these  have  a  truly  state  or  inter-community  bearing, 
i.e.,  when  other  districts  than  the  one  in  question  are  injured 

31 


32  A  MANUAL  FOR   HEALTH  OFFICERS 

or  threatened.  There  is  a  tendency  at  the  present  time 
to  keep  the  degree  of  supervision  of  the  state  over  local 
boards  of  health  very  slight,  too  slight,  in  fact,  in  many 
instances,  to  insure  the  maintenance  of  proper  minimum 
standards  by  those  boards. 

ADVISORY    FUNCTIONS    OF    STATE 
AUTHORITIES 

Under  the  head  of  advisory  functions  state  health  author- 
ities maintain  the  following  classes  of  activities. 

1 .  Investigation.  —  Progressive  state  departments  carry 
on  various  kinds-  of  research  —  laboratory,  statistical  and 
in  the  field  —  such  as  experimental  work  in  bacteriology 
and  chemistry  in  their  sanitary  applications,  statistical 
and  field  investigations  of  conditions  and  administration 
throughout  the  state,  and  the  like.  A  great  deal  of  the 
information  gathered  is  used  in  public  enlightenment  and 
in  advice  to  local  boards  of  health. 

2.  Expert  Advice  and  Information  to  Local  Boards  of 
Health.  —  Problems  in  the  control  of  comniunicahle  disease 
constitute  the  largest  class  of  matters  concerning  which 
state  advice  is  sought.  Such  service  is  invaluable  in  con- 
nection with  epidemics,  as  also  when  a  rare  disease  appears. 
Local  authorities  show  wisdom  in  seeking  state  cooperation 
in  any  situation  which  is  difficult  or  which  threatens  to 
become  so.  Such  a  move  does  not  signify  local  incompe- 
tence, but  prudence.  Every  state  department  should 
have  in  its  staff  trained  epidemiologists,  specialists  who  arc 
much  more  expert  in  dealing  with  the  unusual  aspects  of 
communicable  disease  than  the  local  health  officer  can 
possibly  be,  and  to  seek  their  services  is  frequently  wisdom 
on  the  part  of  the  latter.  This  is  especially  true  in  the 
smaller  towns,  where  experience  of  communicable  disease 
is  limited.  Frequently  application  for  a  state  inspector 
in  the  early  stages  of  an  epidemic  in  such  a  town  will  result 


STATE  HEALTH  AUTHORITIES  33 

in  obtaining  advice  which  will  clear  up  a  situation  which 
might  otherwise  have  resulted  disastrously.  In  case  there 
is  public  apprehension,  resistance  or  criticism,  they  are 
abated  in  the  presence  of  state  authority.  The  state 
inspector,  furthermore,  will  recognize  the  larger  aspects  of 
an  epidemic:  e.g.,  the  possible  danger  of  spread  of  the 
infection  to  other  communities  through  milk-supplies  or 
by  the  traveling  of  infected  persons.  It  is  for  such  reasons 
that  cases  of  communicable  disease  occurring  on  dairy 
premises  or  among  dairy  employees  should  be  dealt  with 
by  the  state  authorities;  in  some  states  the  law  requires 
that  they  be  so  controlled. 

Under  the  head  of  laboratory  service  to  local  boards, 
bacteriological  service  in  the  diagnosis  of  communicable 
disease,  when  the  local  board  has  no  facilities,  is  usually 
furnished.  Thus  boards  of  health  and  physicians  in  small 
places  may  transmit  cultures  of  diphtheria,  etc.,  to  the  state 
bacteriologist  for  examination.  This  procedure,  as  already 
remarked,  is  by  no  means  ideal,  yet  may  be  the  best  avail- 
able. 

Other  valuable  laboratory  service  to  local  boards  is 
frequently  provided;  thus  in  some  states  diphtheria  anti- 
toxin, Pasteur  treatment  for  rabies  and  other  sera  are 
furnished.  In  the  same  way  samples  of  water  and  foods 
(especially  milk)  may  be  analyzed  for  the  local  authorities, 
with  advice  on  the  analytical  results.  Some  state  boards 
provide  outfits  of  prophylactic  solution  for  free  distribution 
to  physicians  and  midwives  for  the  prevention  of  oph- 
thalmia neonatorum  (see  p.  240). 

Special  questions  somewhat  beyond  the  province  of  the 
local  counsel  —  on  legal  procedure,  proposed  ordinances, 
powers  and  the  like  —  may  be  submitted  to  state  health 
authorities  or  state  attorney-general  for  advice.  The 
state  authorities  should  have  a  close  familiarity  with  the 
statutory  health  powers  and  with  the  ordinances  adopted 
by  the  various  local  boards  of  health  and  how  these  have 


34  A  MANUAL   FOR  HEALTH  OFFICERS 

Worked  out  in  practice  and  before  the  Courts;  and  should 
consequently  be  able  to  render  effective  advice  on  all 
such  matters.' 

3.  Cooperation  with  Local  Authorities  in  Raising 
Standards  of  Administration.  —  State  departments  are 
in  a  position  to  standardize  metliods  and  forms  and  to  devise 
plans  for  uniform  composition  and  reporting  of  certain 
data,  especially  statistical  data.  There  is  unquestionably 
a  great  deal  of  confusion  and  ineffectiveness  among  local 
boards  which  might  be  removed  by  such  means.  Without 
the  repression  of  the  experimental  and  practical  diver- 
gencies which  must  necessarily  and  properly  exist  among 
local  boards,  a  common  agreement  upon  the  main  results 
to  be  aimed  at,  the  principal  recognized  methods  of  at- 
tack and  the  terms  in  which  results  are  to  be  expressed 
is  one  of  the  chief  needs  of  the  present  day. 

A  most  important  opportunity  of  state  departments 
consists  in  arranging  for  state  conferences  at  which  the  health 
olScers  from  the  various  communities  meet  for  reading 
of  papers  and  discussion  of  the  many  pressing  questions 
arising  out  of   their  work.     Such   conferences  have  been 

^  As  an  example  of  effective  information  to  local  authorities  we  may 
mention  the  valuable  "Public  Health  Manual"  issued  by  the  New 
York  State  Department  of  Health  for  the  guidance  of  local  health 
officers  and  boards.  It  contains  not  only  the  public  health  law,  but 
also  model  sanitary  regulations,  instructions  to  health  officers  and  to 
registrars,  instructions  regarding  the  various  communicable  diseases, 
and  other  useful  matter  relative  to  state  and  local  boards  of  health. 
Bender's  "Health  Officer's  Manual  and  Public  Health  Law  of  the 
State  of  New  York"  supplements  this,  containing  annotations  on  the 
law,  an  explanation  of  powers  and  duties  of  local  health  authorities, 
recommended  sanitary  regulations,  state  department  information 
for  officials  and  private  individuals  regarding  communicable  diseases, 
and  forms  (pub.  Bender  and  Co.,  Albany,  N.  Y.).  The  Manual  of 
the  Laws  relating  to  the  Public  Health,  issued  by  the  Massachusetts 
State  Board  of  Health,  fills  a  similar  need  in  collating  laws  and  court 
decisions.  Such  studies  and  codifications  of  the  health  laws  are  highly 
useful  and  should  be  available  in  every  state. 


STATE  HEALTH   AUTHOR  ITIIOS  35 

held  with  excellent  effect  in  New  York,  C.'onnecticut,  New 
Jersey  and  other  states.  At  least  an  annual,  and  prefer- 
ably a  quarterly,  conference  should  be  held  in  every  state. 
Conferences  may  be  held  not  only  at  the  state  capital,  but 
also  at  various  convenient  jx^nts  in  the  state.  Each 
health  officer  should  have  a  general  authorization  from  his 
board  to  attend  such  conferences,  and  legislative  provi- 
sion should  be  made  that  each  municipality  pay  the  neces- 
sary expenses  of  its  health  officer  (and  perhaps  certain 
other  employees)  incurred  in  such  attendance.  At  such 
conferences  peculiarly  local  problems  are  discussed  and 
invaluable  opportunity  afforded  local  officers  to  meet  the 
state  officials  and  one  another.  We  may  add  that  experi- 
ence has  shown  the  advisability  of  forming  a  state  health 
officers'  association,  which  cooperates  with  the  state  health 
authorities  in  calling  conferences,  arranging  programs  for 
them,  and  stimulating  interest  on  the  part  of  the  local 
officials. 

State  authorities  have  an  important  duty  to  perform  in 
endeavoring  to  raise  the  professional  standard  of  health 
officers  and  inspectors.  This  it  may  do  by  obtaining 
through  legislation  a  minimum  legal  standard  for  the  quali- 
fications of  sanitary  officers,  and  by  providing  for  the 
instruction  of  such  men  (either  practicing  or  as  candidates 
for  office)  as  may  be  deficient  in  any  subjects.  The  State 
Departments  of  Health  of  New  York  and  Kansas,  for 
example,  maintain  regular  courses  for  health  officers  in 
sanitary  science  and  laboratory  practice.^  In  New  Jersey 
there  has  been  in  operation  since  1904  a  law  requir- 
ing that  all  health  officers  and  sanitary  inspectors  practic- 
ing in  the  state  hold  a  license  from  the  State  Board  of 
Health,  such  license  to  be  granted  only  upon  passing 
written  and  oral  examinations.  This  particular  plan  has 
certainly    improved    the    average    qualifications    of    local 

^  It  has  been  suggested  that  good  results  might  be  obtained  from 
correspondence  courses  (Trask,  in  Pub.  Health  Rpts.,  Sept.  4,  1914). 


36  A  MANUAL   FOR   HEALTH  OFFICERS 

officers  through  the  elimination  of  unfit  candidates.  It  is 
based  upon  a  good  principle  and  would  yield  much  better 
results  were  it  not  for  two  serious  obstacles.  One  of  these 
is  the  lack,  in  that  Slate,  of  means  of  instruction  for  actual 
or  prospective  sanitary  officers;  the  other,  more  deeply 
rooted,  is  the  failure  of  many  municipalities  to  pay  a 
sufficient  salary  to  induce  such  officers  to  prepare  them- 
selves by  adequate  study  for  their  positions.  In  this  pass, 
since  there  is  an  insufficient  number  of  properly  qualified 
men  and  the  state  authorities  cannot  therefore  reasonably 
attempt  to  force  local  communities,  the  law  is  only  partly 
fulfilled.  Nevertheless,  it  points  the  way  to  a  truly  efTec- 
tive  system  of  qualifying  and  licensing  health  officers  and 
inspectors. 

Some  state  departments  maintain  a  bulletin  service,  one 
of  the  objects  of  which  is  to  keep  in  touch  with  local 
health  officers  and  boards  on  matters  of  administrative 
interest.  (The  bulletin  as  a  means  of  publicity  will  be 
spoken  of  later.)  Such  a  bulletin  is  a  very  important 
factor  in  raising  and  supporting  high  standards  and  in 
disseminating  important  information  and  advice.  Changes 
in  the  health  laws,  new  regulations  promulgated  by  the 
state  health  department,  ordinances  of  special  interest 
adopted  by  local  boards,  advances  in  sanitary  science  and 
practice,  the  communicable  disease  situation,  and  many 
other  matters  are  by  this  means  presented  fresh  to  the 
local  official.  Subjects  which  have  been  or  will  be  dis- 
cussed in  conferences  may  be  introduced  and  important 
papers  presented  at  the  conferences  may  be  printed. 
Concise  abstracts  of  articles  published  in  various  profes- 
sional periodicals  and  the  like  may  be  printed  for  the 
perusal  of  the  busy  health  officer.  The  Departments 
of  Health  of  New  York,  Massachusetts,  Virginia,  Kansas, 
North  Carolina,  California  and  other  states  maintain  such 
bulletins  with  excellent  effect.  However  much  popular 
matter  or  statistical  tabulations  such  a  bulletin  may  con- 


STATE   HEALTH   AUTHORITIES  37 

tain,  a  generous  share  of  space  should  be  allotted  directly 
to  the  interests  and  needs  of  the  local  hoard  and  health 
ofificer. 

4.  Cooperation  with  Universities.  —  Opportunities  for 
mutual  benefit  lie  in  cooperation  of  state  health  depart- 
ments with  educational  institutions  which  carry  on  work 
in  sanitary  science  and  public  health.  The  plan  has  been 
adopted,  with  some  success,  between  state  boards  and 
state  universities,  in  some  of  the  states.  While  as  yet 
the  idea  is  in  a  tentative  stage,  there  are  undoubtedly 
advantages  in  such  cooperation  under  favorable  circum- 
stances.^ Under  such  an  arrangement  the  state  health 
authorities  may  be  enabled  to  profit  by  the  services  of 
expert  university  specialists,  to  obtain  more  extensive 
research  work  than  otherwise,  and  to  have  the  use  of 
Well-equipped  laboratories  and  libraries  without  great 
expenditure;  while  the  university  instructors  have  the 
opportunity  for  research  and  service  in  practical  fields, 
and  the  university  students  for  study  of  professional  prac- 
tice and  problems  at  first  hand. 

5.  Publicity.  —  In  publicity  work  state  health  depart- 
ments have  a  wide  and  important  field.  The  newspaper 
press  deserves  special  mention  as  being  the  most  powerful 
means  of  publicity  today.  A  great  deal  of  the  data  col- 
lected by  state  authorities  can  be  worked  up  into  readable, 
and  at  the  same  time  educative,  press  material  instead  of 
being  simply  filed  away  in  official  reports  or  even  bulletins. 
Those  state  health  departments  which  carry  on  a  regular, 
active  press  service  for  the  newspapers  are  taking  by  far 
the  shortest  route  to  the  public  mind. 

Many  state  health  departments  issue  for  popular  instruc- 
tion printed  matter,  such  as  bulletins,  circulars,  posters  and 
the  like.     We  have  mentioned  above  some  of  the  states 

'  See  discussions  by  representatives  of  several  states  before  the 
American  Public  Health  Association  in  1910  {Jour.  Am.  Pub.  Health 
Assn.,  1911,  vol.  I,  p.  544  ff.). 


38  A   MANUAL   FOR   HEALTH   OFFICERS 

which  issue  efTective  periodical  Inilletins.  Such  a  bulletin 
usually  has  two  objects  in  view:  the  benefit  of  the  local 
health  officer  and  the  benefit  of  the  public.  The  former 
object  has  alread>'  been  mentioned  abo\'e.  It  seems  advis- 
able that  so  far  as  possible  the  two  classes  of  matter  be 
printed  and  circulated  separately,  some  going  into  the 
bulletin  for  health  officers  and  some  into  popular  bulletins 
and  an  acti\'e  i^ress  service. 

The  annual  reports  of  state  boards  of  health  contain 
much  matter  of  interest,  but  such  reports  are  usually  more 
or  less  delayed  and  a  great  deal  of  the  matter  would  be  of 
greater  effect  if  issued  more  promptly  in  the  shape  of  press 
news  bulletins,  and  the  like. 

Popular  exhibits  constitute  part  of  the  publicity  arsenal 
of  some  state  departments.  Thus  the  New  Jersey  State 
Board  of  Health  maintains  a  traveling  tuberculosis  exhibit 
which  is  successfully  shown  in  various  towns  under  the 
auspices  of  the  local  board  of  health,  school  authorities, 
anti-tuberculosis  society  and  other  organizations.  In 
California  and  other  states  exhibit-cars  have  been  fitted 
up  and  put  on  the  road  for  short  stops  in  out-of-the-way 
places  which  it  would  be  impracticable  to  reach  otherwise. 
Exhibits,  moved  from  place  to  place,  stir  up  local  interest 
and  stimulate  local  action,  and  are  therefore  highly  valuable 
factors  in  the  leadership  of  the  state  departments  in  cam- 
paigns against  tuberculosis,  for  improved  milk  supplies 
and  the  rest. 

EXECUTIVE    FUNCTIONS    OF    STATE 
AUTHORITIES 

State  authorities  may  exercise  executive  power  when 
a  condition  existing  in  one  sanitary  district  affects  another 
district,  or  when  the  matter  to  be  dealt  with  affects  two 
or  more  districts  in  common  and  is  best  administered  by 
central  authority.  The  various  executive  activities  of  state 
authorities  may  be  summarized  under  the  following  heads: 


STATE   HEALTH    AU'IIIOKI'I  IKS  39 

1.  Communicable  Disease.  —  When  cases  of  a  trans- 
missible disease  threaten  more  than  one  sanitary  district, 
state  authorities  may  have  power  to  institute  general 
quarantines  and  to  perform  other  such  executive  functions. 
The  control  of  communicable  disease  on  or  affecting  dairy 
premises  (where  the  infection  might  be  transmitted  to 
citizens  in  another  and  perhaps  far-distant  part  of  the 
state)  is  an  example  of  the  exercise  of  such  power. 

2.  Nuisances. — ^When  a  nuisance  located  on  one  sani- 
tary district  affects  another  district,  the  state  authorities 
may  have  executive  power  to  order  abatement,  and  if 
necessary,  to  institute  legal  suit. 

3.  Registration  of  Vital  Records.  —  The  maintenance 
of  a  thorough  and  comprehensive  system  for  the  registra- 
tion of  records  of  births,  deaths  and  marriages  is  the  chief 
duty  of  the  state  health  department.^  No  efficient  system 
can  be  obtained  without  strong  central  control,  a  fact 
which  has  now  been  recognized  in  many  of  the  states. 

The  function  of  the  state  registrar  consists  in: 

(i)    Inspection  of  certificates  received  for  the  detection 

of  inaccuracies  and  deficiencies  which  may  have  escaped 

the  notice  of  the  local  registrar. 

(2)  Filing  for  permanent  legal  record  and  for  statis- 
tical purposes. 

(3)  Statistical  tabulations  and  study.  As  regards  san- 
itary administration,  the  publication  of  good  statistical 
reports  and  studies  is  the  final  aim. 

The  collection  of  morbidity  records  (i.e.,  records  of 
sickness)  is  another  duty  of  the  state  authorities.  The 
movement  in  this  direction  is  of  comparatively  recent 
but  promising  development.  Local  health  officers  are 
required  to  forward  at  short  intervals  to  the  state  depart- 

^  This  duty  may  be  lodged  with  some  other  department  of  the 
state  government,  but  it  seems  altogether  most  desirable,  for  reasons 
which  will  be  set  forth  later,  that  it  should  be  under  the  department 
of  health. 


40  A  MANUAL  FOR   HEALTH   OFFICERS 

niciiL,  not  necessarily  to  the  state  registrar  but  rather  to 
the  division  of  communicable  diseases,  statements  of  the 
local  numl)crs  (and  sometimes  detailed  data)  of  cases  of 
communicable  diseases.  (The  requirement  may  also  em- 
brace occupational  diseases,  epilepsy  and  other  diseases 
reportable  by  physicians.)  The  incidence  and  distribu- 
tion of  the  cases  are  noted  and  studied  in  various  ways. 
They  may  form  the  basis  for  investigation,  advice  or 
warning  in  case  of  unusual  local  conditions  in  any  instance. 
The  mortality  records  may  also  be  used  as  a  check  on  the 
completeness  of  registration  of  communicable  disease,  and 
action  may  be  taken  to  keep  the  local  authorities  up  to 
their  duty  in  this  respect. 

In  the  development  of  systems  of  registration  of  vital  records  (using 
that  term  in  the  broadest  sense),  state  departments  of  health  have 
large  responsibilities  and  opportunities.  At  the  official  head  of  the 
movement  for  better  mortality  statistics  is  the  Federal  Bureau  of  the 
Census,  which  endeavors  to  obtain  completeness  and  accuracy  in 
the  returns  throughout  the  country,  as  shown,  for  example,  in  its  distinc- 
tion between  "registration"  and  "non-registration"  states.  In  this 
work  it  is  supported  and  assisted  by  the  U.  S.  Public  Health  Service, 
the  Vital  Statistics  section  of  the  American  Public  Health  Association 
and  other  organizations.  In  this  work  the  individual  states  through 
their  departments  of  health  and  their  registration  officers,  play  a  most 
important  part.  The  divergences  among  the  various  states  in  laws 
and  methods  are  wide,  but  at  the  present  time  efforts  are  being  made 
to  obtain  uniformity  in  all  essentials.  Such  efforts  involve  the  estab- 
lishment of  national  standards  which  should  eventually  be  univer- 
sally adopted  throughout  the  country. 

The  requirements  for  an  efficient  state  registration  system  may  be 
summarized  as  follows: 

(a)  An  adequate  state  registration  law,  including  among  others 
the  following  provisions. 

(b)  Uniform  blank  forms,  based  upon  the  best  statistical  practice, 
prescribed  for  use  throughout  the  state. 

(c)  Legal  requirement  that  the  local  registrar  be  an  officer  of  the 
local  board  of  health,  rather  than  the  town  clerk  or  other  official.' 

'  In  New  Jersey  a  bill  was  introduced  in  191 3  (by  request  of  the 
State  Health  Officers'  Association)  providing  that  a  local  board  may 
appoint  a  registrar  who  thereupon  is  entitled  to  full  charge  of  records 


STATE   HEALTH  AUTHORITIES  4 1 

(d)  Legal  provision  for  sufficient  \>iiy  lo  such  registrar,  either  by 
salary  or  fees,  to  compensate  for  efficiency  in  the  jierformance  of 
duty. 

(e)  Insistence  by  the  local  registrar  on  promjit  filing  of  all  certifi- 
cates and  on  fullness  and  accuracy  in  the  same. 

(f)  Accurate  local  transcription  and  checking  of  certificates,  and 
periodical  forwarding  of  them,  as  should  be  reciuired  by  law,  to  the 
state  registration  office,  a  bureau  of  the  state  department  of  health. 

(g)  Finally,  systematic  watchfulness  on  the  part  of  the  state  reg- 
istration authorities  over  the  accuracy  and  completeness  of  local  re- 
turns, and  the  power  on  their  part,  not  only  to  ensure  the  performance 
of  duty  by  local  registrars,  but  also  to  bring  suit  themselves,  if  need 
be,  against  physicians  and  others  responsible  for  making  returns. 

All  of  which,  it  is  evident,  depends  largely  upon  the  activity  and 
vigilance  of  the  state  authorities. 

4.  Food  and  Drugs.  —  The  enforcement  of  the  complex 
and  far-reaching  food  and  drug  laws  is  best  managed  by  the 
state  department  of  health  with  its  expert  inspectors  and 
analysts,  its  special  laboratories  and  its  experience  over 
a  wide  area.  The  state  laws  on  the  subject,  it  may  be 
noted,  are  largely  patterned  after  the  Federal  Pure  Food 
Law.  This  is  fortunate,  for  differences  in  the  state  stand- 
ards in  this  intricate  matter  would  at  once  lead  to  confusion 
and  impaired  authority.  State  officials  investigate  con- 
ditions as  to  manufacture,  storage,  transportation  and 
distribution,  and  collect  samples  for  analyst.  State 
licenses  may  be  required  for  certain  classes  of  establish- 
ments, such  as  bakeries,  ice-cream  and  confectionery 
factories,  and  the  like,  which  may,  however,  be  required 
to  conform  to  local  regulations  as  well.  Through  such 
state  activity  local  boards  of  health  are  not  curtailed 
in  their  authority,  but  are  relieved  of  a  good  deal  of  spe- 
cialized work  of  a  state-wide  character,  which  they  are 
commonly    unable   properly    to    perform   for   themselves. 

of  births,  marriages  and  deaths,  relieving  the  town  clerk  or  recorder 
of  that  duty.  The  bill  was  made  permissive  in  order  that  only  those 
boards  appreciating  the  responsibility  and  prepared  to  take  proper  care 
of  the  records  would  assume  charge  of  them. 


42  A  iI.\NU.\L   FOR  HEALTH  OFFICERS 

Altogether    this    constitutes    one    of    the    most    effective 
branches  of  state  executive  activity. 

In  the  supervision  of  milk-sui:)pHes,  state  control  has  a 
special  value  in  relation  to  dairies  and  creameries  which 
ship  from  one  part  of  the  state  to  another.  The  state 
authorities  can  readily  supervise  widely  scattered  dairies 
as  well  as  the  conditions  in  transit.  Later,  under  the  head 
of  milk-supplies  we  shall  revert  to  this  point  in  some  detail. 

5.  Water  Supplies  and  Sewage  Disposah  —  Arbitrary 
powers  of  approval  or  disapproval  of  the  water-supplies 
of  municipalities,  as  based  upon  sanitary  investigation, 
may  be  conferred  upon  state  boards  of  health.  Thus, 
for  example,  in  Massachusetts,  which  has  one  of  the  oldest 
and  most  comprehensive  laws  on  the  subject,  the  State 
Board  of  Health  may  make  rules  and  regulations  for  the 
protection  of  water-supplies,  and  no  municipality  may 
introduce  a  new  system  of  water-supply  without  the  ap- 
proval of  the  Board.  The  Board  has  corresponding  powers 
in  relation  to  sewage-disposal  throughout  the  State.  Thus 
also  the  Engineering  Division  of  the  Michigan  State 
Board  of  Health,  created  in  1913,  has  supervision  of  all 
sewer  and  water  systems  in  the  State,  has  power  to  deal 
with  stream  pollution,  conducts  investigations  of  water- 
supply  and  sewerage,  including  trade  wastes,  and  gives 
advice  to  municipalities. 

6.  Factories,  Tenements,  etc.  —  State  boards  of  health 
usually  have  at  least  general  powers  of  inspection  and 
sanitary  control  of  factories  and  tenements,  and  sometimes 
of  schools.  This  function  includes  also  sanitary  super- 
vision of  the  public  institutions  of  the  state,  such  as  prisons, 
hospitals,  etc.  In  Massachusetts,  for  example,  factory 
and  other  inspections  were  until  recently^  performed  by 
a  body  of  State  Inspectors  of  Health  under  the  State 
Board  of  Health,  their  investigations  being  published  in  a 
series  of  annual  reports.     Owing,  however,  to  the  specialized 

^  Transferred  in  1913  to  the  State  Bureau  of  Labor  and  Industries. 


STATE  HEALTH   AU'IIIORI'IIES  43 

nature  of  tenement  and  factory  inspection  and  to  the  fact 
that  the  questions  of  safety  as  well  as  health  are  involved, 
there  is  a  tendency  to  assign  these  matters  to  special  de- 
partments of  the  state  government  distinct  from  the  health 
department,  while  matters  of  school  hygiene  arc  being  left 
more  largely  to  the  educational  authorities. 

7.  Transportation  and  Marine  Quarantine.  —  Writing 
in  1900  on  the  status  of  public  hygiene  in  the  United  States, 
Dr.  Abbott  (in  a  monograph  for  the  U.  S.  Commission  to 
the  Paris  Exposition)  remarked  of  railway  sanitation : 

At  the  present  time  almost  the  only  legislation  on  this  subject  is 
that  which  exists  in  a  few  states  in  relation  to  the  transportation  of 
dead  bodies,  and  specially  regarding  the  bodies  of  those  who  have 
died  of  infectious  diseases.  Yet,  it  is  a  matter  of  certainty  that  a 
living,  breathing  human  being,  sick  with  an  infectious  disease,  is  a 
far  greater  danger  to  persons  in  his  immediate  proximity,  than  the 
body  of  one  who  has  died  of  the  same  disease,  and  is  enclosed  in  a  coffin. 
.  .  .  Legislation  intended  for  the  protection  of  the  traveler  from  the 
sick  and  living  is  of  far  more  importance  than  that  which  is  designed 
to  protect  him  from  the  dead. 

Now,  fortunately,  broader  views  are  taken  of  the  hygiene 
of  transportation  than  those  entertained  by  the  state 
authorities  and  legislators  of  that  date.  Sanitation  on 
board  trains  and  boats  and  in  railroad  stations;  the  aboli- 
tion of  the  common  drinking  cup  and  towel  in  trains, 
stations  and  other  public  places;  the  sanitation  of  road- 
beds in  relation  to  the  spread  of  disease  through  the  drop- 
ping of  excreta  (particularly  through  the  pollution  of 
watersheds  through  which  railroads  may  run);  regulation 
of  the  care  of  milk  and  other  foods  in  transit;  restrictions 
on  the  transportation  of  infected  persons;  and  other 
related  matters  are  now  recognized  —  or  beginning  to  be 
recognized  —  as  responsibilities  of  the  state  health  author- 
ities. The  oversight  of  the  sanitation  of  construction 
camps  on  railroads  is  a  duty  of  the  same  class. 

The  quarantine  of  ports  of  entr}^  in  maritime  states  is 
sometimes  assigned  to  state  authority,  although  this  is  a 


44  A   MANUAL  FOR   HEALTH  OFFICERS 

matter  varying  from  state  to  state,  in  which  the  municipal 
government  of  the  port  and  the  Federal  Government  may 
also  have  a  share. 

8.  Manufacture  of  Antitoxins  and  Vaccines.  —  The 
state  health  authorities  should  properly  have  supervision 
over  the  manufacture  of  all  antitoxins  and  vaccines  pro- 
duced in  the  state.  Actually,  most  if  not  all  such  estab- 
lishments engage  in  interstate  trade  and  are  therefore 
subject  to  supervision  by  the  Hygienic  Laboratory  of  the 
U.  S.  Public  Health  Service.  In  order  to  provide  reliable 
antitoxins  and  vaccines,  at  low  cost,  for  local  boards  and 
private  sale,  the  state  health  department  (as  now  in  several 
states)  may  by  special  legislative  authorization  undertake 
the  manufacture  and  distribution  of  diphtheria  antitoxin, 
smallpox  vaccine,  typhoid  vaccine,  Pasteur  rabies  treat- 
ments and  other  products  of  this  class. 

9.  Hospitals  and  Sanitoria.  —  The  duty  of  establishing 
and  operating,  or  at  least  of  supervising,  hospitals  and  sani- 
toria for  tuberculosis  and  other  diseases  may  be  assigned 
to  the  state  health  authorities.  Frequently,  however,  such 
duties  are  assigned  to  a  separate  state  department  or  to  the 
counties. 

10.  Local  Executive  Action  and  Supervision  over  Local 
Authorities.  —  In  exceptional  instances  the  state  authorities 
may  exercise  purely  local  power  in  place  of  that  of  the  local 
board  of  health.  Thus,  in  New  York  State,  if  a  muni- 
cipality fails  to  establish  a  board  of  health,  the  state 
commissioner  is  authorized  to  act  instead,  appointing  a 
health  officer  and  fixing  his  duties  and  compensation, 
the  latter  being  paid  by  the  municipality.  Again,  in 
Indiana,  the  state  board  of  health  is  empowered  to  remove 
local  health  officers  for  incompetence.  In  Massachusetts 
the  state  board  has  coordinate  powers  with  the  local 
board.  Powers  overruling  those  of  the  local  authorities 
are,  however,  reserved  for  unusual  circumstances,  as  are 
coordinate  powers,  which  moreover  may  result  in  division 


STATK    IIKAI/f'ir    Ain'FIORI'IIICS  45 

or  clashing  of  authority.  The  usual  way  for  state  author- 
ities to  stimulate  and  assist  local  auth(;rities  is  thrrnigh 
cooperative  advice,  and  such  powers  as  they  may  hold 
over  the  latter  are  properly  designed  chiefly  to  insure  a 
minimum  degree  of  activity. 

An  instance  of  state  action  in  local  affairs  for  the  jiro- 
tection  of  the  people  of  the  state  in  general  may  be  seen 
in  New  York.  There  serious  problems  arc  [ound  in  sum- 
mer resorts,  where  certain  unsanitary  conditions  exist  as 
a  detriment  to  vacationists  coming  from  other  places. 
The  great  increase  in  population  in  such  places  during 
the  summer  months  is  in  itself  a  serious  matter,  meaning 
increased  problems  of  water-supply,  milk-supply  and  the 
disposal  of  wastes.  Such  problems  the  local  authorities 
perhaps  cannot  or  will  not  cope  with.  The  New  York 
State  Health  Department  has  opened  up  a  promising  line 
of  attack  in  making  a  survey  of  all  summer  resorts  in  the 
state  and  publishing  in  its  monthly  bulletin  or  in  the 
newspaper  press  the  names  and  locations  of  those  estab- 
lishments which  fail  to  comply  with  repeated  orders  to 
eliminate  unsanitary  conditions.  While  such  action  is  not 
strictly  executive,  it  has  much  the  same  effect  in  taking  the 
place  of  local  action. 

There  is  a  sentiment  in  some  quarters  that  state  health 
authorities  should  exercise  a  greater  degree  of  supervision 
over  the  activities  of  local  authorities.  If  the  state  depart- 
ment is  thorough  and  alive  to  the  best  practice,  some  sort  of 
regular  inspection  service  to  insure  adequate  local  organiza- 
tion and  methods  is  very  desirable.  In  New  York  State  (see 
below)  such  supervision  goes  so  far  as  to  take  over  the  func- 
tions of  the  rural  local  boards,  the  latter  being  abolished. 

In  the  performance  of  its  executive  functions  the  state 
board  of  health  acts  in  the  same  manner  as  the  local  board: 
it  has  the  power  to  make  regulations,  to  inspect  and  exam- 
ine, to  deliberate,  notify,  warn,  advise,  and,  finally,  if 
necessary,  to  institute  legal  proceedings. 


46  A  MANUAL   FOR   HEALTH  OFFICERS 

STATE  ORGANIZATION 

In  general  two  different  forms  of  state  organization 
exist,  according  to  whether  the  supreme  power  is  vested 
in  a  hoard  or  in  a  commissioner. 

In  nearly  all  of  the  states  the  former  is  the  case.  Thus 
in  Massachusetts,  where  the  earliest  state  board  was  estab- 
lished, that  board  consists  of  "  seven  persons,  one  of  whom 
shall  be  annually  a]ipoinled  by  the  governor,  with  the 
advice  and  consent  of  the  [governor's]  council,  for  a  term 
of  seven  years."  The  members  serve  without  compen- 
sation (though  this  is  not  the  case  in  all  states),  and  the 
board  has  long  been  noted  for  its  high  personnel.  Such 
a  board  must  of  course  have  an  executive  ofificer,  analogous 
to  the  local  health  ofhcer,  to  direct  the  work  of  its  staff. 
This  ofificer  is  usually  the  "  secretary,"  though  sometimes 
the  president  of  the  board  or  a  specially  appointed  "  health 
commissioner," 

The  second  plan  is  well  illustrated  in  New  York  State, 
where  a  radical  change  was  adopted  in  1901,  confirmed  by 
the  reorganization  law  of  191 3,  by  the  abolition  of  the 
state  board  of  health  and  the  substitution  of  a  state  "  com- 
missioner of  health  "  having  all  the  powers  and  performing 
all  the  duties  of  the  former  board.  For  his  guidance  and 
support,  the  New  York  Commissioner  has  the  assistance 
of  an  Advisory  Council  consisting  of  two  laymen,  one 
sanitary  engineer,  three  physicians  and  the  commissioner. 
In  Pennsylvania  a  similar  plan,  with  even  more  local  power, 
is  in  operation.  The  New  York  plan  combines  the  advan- 
tages of  concentrated  executive  control  with  the  stability 
of  a  competent  deliberative  board. 

Attention  has  recently  been  called^  to  the  predominant 
influence  which  the  medical  profession  has  exerted  and 
still  exerts  in  state  (as  well  as  local)  boards  of  health. 
Although    that    profession    has   unquestionably    played    a 

^  See  footnote  p.  14. 


STATE   HEALTH   AUTHORITIES  47 

large  part  in  the  development  of  i)ublic  hygiene,  and 
should  have  a  representation  on  every  such  board,  never- 
theless hygiene  has  widened  and  become  more  and  more 
specialized  until  we  can  see  that  several  other  classes  of 
men  are  needed  on  our  health  boards.  The  founder  of 
modern  public  health  science  —  Pasteur  —  it  must  be 
remembered,  was  not  a  physician,  but  a  chemist,  biologist 
and  bacteriologist;  and  he  has  been  followed  by  a  company 
of  other  specialists  in  those  sciences,  as  well  as  by  sanitary 
engineers  and  social  workers  who  have  done  much  to 
further  the  public  health.  It  is  interesting  to  note  that 
such  facts  were  taken  into  account  by  the  far-seeing  State 
Sanitary  Commission  of  Massachusetts  over  sixty  years 
ago  when  it  recommended  that  the  state  board  include, 
besides  two  physicians,  "  one  counsellor  at  law,  one  chem- 
ist, one  natural  philosopher,  one  civil  engineer  and  two  per- 
sons of  other  profession  or  occupation,  all  properly  qualified 
for  the  office."  And  the  importance  of  representation  other 
than  medical  has  increased  since  that  time,  for,  as  the 
public  health  specialist  develops,  the  need  for  the  medical 
man  lessens.  As  for  the  chief  sanitary  executive  of  the 
state,  while  strict  requirements  as  to  professional  training 
and  accomplishment  should  be  upheld,  requirements  that 
he  be  necessarily  a  physician  might  well  be  abolished, 
while  professional  sanitarians  and  others  who  in  any  proper 
way  have  achieved  the  requisite  qualifications  as  sanitary 
administrators  are  entitled  to  an  equal  chance. 

Details  of  organization  and  procedure,  difTering  as  they 
do  from  state  to  state,  need  not  be  taken  up  here.  Every 
well-organized  state  health  department  has,  working  under 
its  general  administration,  divisions  (actually  if  not  nomi- 
nally) of  vital  records,  of  communicable  disease,  of  general 
sanitary  inspection,  of  foods  and  drugs,  of  water-supplies 
and  sewerage,  and  of  publicity,  and  the  necessary  acces- 
sory laboratories.  It  relies  upon  the  attorne^'-general  and 
legal  department  of  the  state  for  legal  advice  and  services, 


48  A  MANUAL   FOR   HEALTH  OFFICERS 

and  may  cooperate  to  a  greater  or  less  extent  with  the 
state  educational  authorities,  agricultural  or  livestock 
authorities  and  others  whose  activity  bears  in  any  special 
way  upon  the  public  health  of  the  state.  The  Massachu- 
setts Department  has  a  corps  of  Inspectors  of  Health, 
each  resident  in  a  district,  who  carry  on  investigations 
and  furnish  advice  to  the  authorities  of  local  communities. 
The  New  York  plan  of  state  supervisors  for  rural  districts 
is  described  below. 

State  Sanitary  Supervision.  —  Of  recent  years  growing 
attention  has  been  paid  to  the  inadequacy  of  the  sanitary 
service  in  rural  districts  throughout  the  country.  This 
attention  comes  late,  for,  while  the  cities  have  been 
forced,  by  the  conspicuous  and  obviously  pressing  nature 
of  their  public  health  problems,  to  make  some  sort  of 
provision  for  health  service,  in  the  country  districts  the 
problems  have  not  been  so  concentrated  and  apparent. 
Nevertheless  it  is  now  a  fact  familiar  to  those  familiar  with 
the  conditions  that  rural  health  administration  in  this 
country  is  to  a  large  extent  inadequate,  both  as  to  funds 
and  as  to  the  methods  of  their  expenditure. 

.  Statistics  show  that  death  rates  in  the  rural  districts 
are  not  decreasing  equally  with  those  in  the  cities,  and  in 
some  cases  are  actually  stationary.^ 

Moreover,  conditions  in  the  rural  districts  do  not  affect 
those  districts  alone,  but  have  a  pronounced  bearing  upon 
the  health  of  the  towns  and  cities  and  constitute  a  state- 
wide problem.     This  is  clear  when  we  consider  the  inter- 

^  "  The  January  [1914]  number  of  the  State  Charities  Aid  Associa- 
tion News,  New  York,  prints  an  interesting  chart  comparing  the  fall  in 
the  death  rates  from  all  causes  of  New  York  City  and  Rural  New  York 
State  (villages  of  less  than  8000)  for  the  period  1900-1913.  During  this 
time  the  city  rate  fell  from  20.6  to  13.7  per  1000,  while  the  rural  rate 
changed  from  15.5  to  15.4  per  1000.  Because  of  this  showing  the  State 
Grange  recommended  to  the  State  Commissioner  of  Health  that  a  divi- 
sion of  rural  hygiene  be  added  to  the  State  Health  Department."  — 
Jotir.  Outdoor  Life,  April,  1914. 


STATE   HEALTH    AUTIFORf'I'IKS  49 

communication,  both  of  persons  and  of  commoflilics, 
between  town  and  country,  which  modern  organization 
and  transportation  facilities  have  made  possible.  Thus 
the  transportation  of  milk  and  other  food  supplies  from 
rural  to  urban  districts  —  regular,  great  in  v(jlume  and 
rapid  in  transit  —  constitutes  an  open  channel  for  the 
infections  which  occur  in  country  districts.  Again,  defi- 
ciencies in  rural  sanitation  may  endanger  city  water- 
supplies  drawn  from  surface  sources  in  the  country.  And 
again,  the  interchange  of  persons  between  city  and  country, 
which  is  now  very  frequent  —  country  people  visiting  the 
city  and  city  people  spending  their  long  vacations  and  even 
their  short  holidays  in  the  country  —  favors  the  inter- 
change of  infections. 

The  fact,  alone  —  that  the  flow  of  potentially  infected 
food-supplies  is  from  the  country  to  the  city  and  from 
single  points  in  the  country  for  wide  distribution  in  the 
city  —  overshadowing  other  considerations  less  clear  and 
apparently  less  important,  indicates  that  on  the  whole  the 
city  has  the  worse  side  of  the  bargain.  And  this  is  true  in 
greater  degree  in  instances  where  insanitation  prevails  in 
the  country  and  at  least  fairly  good  sanitation  in  the 
city. 

Nor  does  criticism  of  rural  districts  apply  onlj^  to  strictly 
agricultural  regions.  It  includes  also  many  small  towns 
of  an  industrial  or  semi-industrial  character,  grouped,  fre- 
quently, about  a  small  factory,  —  communities  which  have 
not  yet  attained  to  the  growth  and  organization  of  cities 
but  which  have  typical  urban  problems  without  the  reme- 
dies of  urban  sanitary  control.  It  is  concentration  of  popu- 
lation, not  the  mere  size  of  the  settlement,  that  constitutes 
the  real  problem.^     In  many  respects  these  nascent  con- 

^  The  sanitary  characteristics  of  communities  of  different  sizes  have 
been  compared  in  a  study  by  W.  T.  Sedgwick,  G.  R.  Taylor  and  the 
present  writer:  "Is  Tj-phoid  Fever  a  'Rural'  Disease?",  Jour.  Inf. 
Diseases,  1912,  vol.  XI,  no.  2,  p.  141. 


50  A  MANUAL  FOR   HEALTH  OFFICERS 

centration  centers  present  the  most  serious  sanitary  prob- 
lem in  America  today. 

Under  present  organization  it  cannot  be  expected  that 
there  will  be  much  immediate  improvement  in  rural  sani- 
tary administration  especially  as  rural  communities  them- 
selves are  content  with  conditions  as  they  are.  The  plan 
of  joint  sanitary  administration  outlined  in  the  last  chapter 
applies  only  to  the  larger  and  more  developed  towns  and 
then  only  under  favorable  circumstances.  Furthermore, 
it  is  interesting  to  note  that  in  the  field  of  education,  where 
consolidated  rural  school  districts  have  been  established 
for  the  purpose  of  increasing  efficiency,  experience  has 
shown  the  need  of  generally  centralized  control  of  rural 
administration,  the  county  being  indicated  as  the  proper 

unit. 

The  New  York  State  Plan 

Great  promise  of  the  solution  of  this  problem  is  now  held 
forth  in  the  recently  adopted  New  York  State  plan.  The 
State  (except  New  York  City)  is  divided  into  twenty  dis- 
tricts each  of  which  is  placed  in  control  of  a  "sanitary  super- 
visor," who  oversees  the  work  of  the  health  officers  and  is 
himself  responsible  to  the  State  Commissioner  of  Health. 
The  latter,  with  the  assistance  of  his  Advisory  Council,  may 
promulgate  a  sanitary  code  to  apply  uniformly  throughout 
the  districts.  The  Supervisors  are  independent  of  local 
influence  and  interference;  they  are  experts  giving  their 
full  time  to  the  work  and  subject  to  no  local  control.  The 
most  primitive  country  community  has  the  benefit  of  the 
most  advanced  methods  of  public  hygiene.  Furthermore 
the  costs  of  supervision  can  be  arranged  to  fall  upon  the 
state  as  a  whole,  so  that  the  large  cities  (which,  as  already 
explained,  derive  a  special  benefit)  pay  their  share.  The 
pay  of  local  health  officers  has  been  placed  at  a  minimum 
of  ten  cents  per  capita  per  year  in  places  of  8000  popula- 
tion and  less. 

It  appears  that  sanitary  administration  in  future  will  be 


STATE   irEAI/I'II   AUTHOR ITIi;S  5I 

much  more  centralized  than  at  present.  Such  has  been 
the  experience  of  older  countries,  such  as  England,  in  their 
development.  In  other  states  plans  similar  to  the  New 
York  plan  have  been  proposed.  The  latter  promises  to 
prove  the  greatest  single  step  forward  in  organization  since 
the  establishment  of  sanitary  authorities  in  this  country. 
If  it  brings  forth  the  results  now  confidently  expected  it 
will  undoubtedly  be  adopted,  at  least  in  principle,  in  other 
states. 


CHAPTER   III 

FEDERAL    HEALTH    AUTHORITIES 

The  Federal  authorities  bear  somewhat  the  same  rela- 
tionship to  those  of  the  States  that  the  latter  do  to  the  local 
boards  of  health;  in  other  words,  their  functions  are  prop- 
erly either  interstate  or  related  to  the  Union  of  States  as  a 
whole  and  are  not  exercised  except  under  conditions  which 
cannot  be  effectively  dealt  with  either  by  local  or  by  state 
authorities.  This  is  in  accordance  with  the  provision  of 
the  Federal  Constitution  that  powers  not  expressly  dele- 
gated by  that  instrument  to  the  Federal  Government  are 
reserved  by  the  individual  states  to  themselves.  Viewing 
the  national  public  health  scheme  as  a  whole,  the  bulk 
of  the  executive  power  is  lodged  with  the  local  boards  of 
health;  less  with  the  state  boards  of  health,  which  are 
therefore  more  advisory  and  less  executive;  and  still  less 
with  the  Federal  Government,  which  is  most  advisory  and 
least  executive. 

ADVISORY  FUNCTIONS 

Most  of  the  advisory  activity  of  the  various  Federal 
public  health  agencies  is  of  a  general  nature.  A  great  deal 
of  investigation  —  consisting  in  laboratory,  statistical  and 
field  work  —  is  carried  on  as  a  basis  for  information  which 
is  distributed  through  the  medium  of  printed  reports  for 
the  benefit  of  the  country  as  a  whole.  The  collection  of 
vital  statistics  on  a  nation-wide  scale  is  an  especially  im- 
portant activity  of  this  kind.  The  facilities  possessed  by 
the  central  government  and  its  wide  range  of  territory  make 
possible  the  prosecution  of  researches  which  would  be  be- 
yond the  resources  of  single  states,  while  at  the  same  time 

52 


FEDERAL   TfllALTH    AUTHORITIES  53 

unnecessary  duplication  among  the  latter  is  avoided.  In 
all  of  this,  however,  there  is  cooperation  with  state  and 
sometimes  with  local  departments  of  health. 

General  information  and  advice,  then,  directed  both  to 
public  officials  and  bodies  and  to  citizens,  is  the  main 
channel  for  the  dissemination  of  the  valuable  results  ob- 
tained by  Federal  research  work. 

Particular  advice  is  also  an  important  service  rendered 
by  the  Federal  agencies.  Aid  on  request  is  given  to  state 
authorities  —  more  rarely  to  local  authorities  —  under 
unusual  circumstances.  A  constant  cooperation  is  kept 
up  between  the  states  and  the  Federal  agencies.  A  con- 
spicuous example  of  aid  on  request  was  the  assistance 
rendered  by  the  Public  Health  Service  (then  the  U.  S. 
Public  Health  and  Marine-Hospital  Service)  to  the  State 
of  California  when  bubonic  plague  appeared  in  San  Fran- 
cisco in  1900  —  although  in  that  case  the  Federal  ofificers 
were  seriously  handicapped  by  the  strong  adverse  influence 
of  commercial  interests.^  Other  emergencies,  such  as  the 
insanitary  conditions  incident  to  the  floods  in  the  Ohio 
and  Mississippi  Valleys  in  the  spring  of  1913,  give  occasion 
for  Federal  investigation  and  advice. 

EXECUTIVE   FUNCTIONS 

The  executive  functions  are  to  be  considered,  as  already 
suggested,  as  they  relate  to  interstate  matters  or  to  national 
matters  affecting  the  country  as  a. whole  or  over  wide  areas. 
Under  the  former  head  fall  the  supervision  of  interstate 
transportation  (sanitation  as  to  water-supply,  etc.,  on 
trains  and  boats) ,  and  the  supervision  over  meat  and  other 
foods,  drugs,  sera  and  other  articles  which  are  shipped  from 
one  state  to  another.  (Power  over  the  pollution  of  inter- 
state streams  is  unfortunately  not  as  yet  included  in  this 
category.)  Under  the  head  of  national  executive  pro- 
tection is  the  Federal  quarantine  system. 

^  See  p.  36  of  the  Memorial  cited  in  footnote  to  p.  57. 


54  A  MANUAL   FOR   HEALTH  OFFICERS 

THE   FEDERAL   BUREAUS 

The  United  States  has  at  the  present  time  no  unified 
national  bureau  or  department  of  health  analogous  to  the 
Comit6  Consultatif  d'Hygiene  of  France,  the  Imperial 
Gesundheitsamt  of  Germany  or  the  Local  Government 
Board  of  England.  The  activities  carried  on  by  the  Federal 
government  for  the  furtherance  of  hygiene  and  sanitation 
are  distributed  among  several  separate  and  distinct  bureaus, 
as  follows: 

In  the  Treasury  Department: 

The  Public  Health  Service  (formerly  the  Public  Health 
and  Marine-Hospital  Service),  which  performs  more  of  the 
functions  of  a  national  health  department  than  any  of  the 
other  existing  Federal  bureaus.  The  Service  has  charge 
of  the  administration  of  the  national  maritime  quarantine 
and  of  the  national  laws  pertaining  to  medical  inspection 
of  immigrants;  conducts  investigations,  in  the  various 
states,  on  infectious  diseases,  maintaining  in  this  connec- 
tion a  Hygienic  Laboratory;  and  regulates  the  purity  and 
potency  of  vaccines,  antitoxins  and  serums  manufactured 
for  sale  in  interstatic  traffic.  Each  year  it  calls  into 
conference  representatives  of  the  state  boards  of  health 
for  discussion  of  scientific  and  administrative  questions 
and  the  promotion  of  cooperation.  It  publishes  weekly 
Public  Health  Reports,  for  circulation  among  health 
authorities  and  others,  setting  forth  statistical  and  other 
data  relating  to  national  quarantine,  communicable  disease 
and  mortality  throughout  the  country,  and  other  related 
subjects.  In  1912  the  Service  was  granted  more  general 
authority  "  to  investigate  the  diseases  of  man  "  and  the 
conditions  related  to  them,  including  in  scope  "sanitation 
and  sewage  and  the  pollution  ...  of  the  navigable 
streams  and  lakes  of  the  United  States." 

The  Hygienic  Laboratory  of  the  Public  Health  Service 
is  conducted  in  four  divisions,  viz.,  bacteriology  and  pathol- 


I'l'lDI'.RAL    FIlCM/ni    AIJIIIOklTIES  55 

ogy,  chemistry,  zoology  and  pharmacology,  and  (arries 
on  a  great  deal  of  important  research  work  in  those  sub- 
jects, the  results  of  which  are  set  forth  in  the  Bulletins  of 
the  Laboratory. 

The  Public  Health  Service,  the  history  of  which  is  a  long 
and  creditable  one  which  cannot  be  detailed  here,  may 
rightly  then  be  regarded  as  the  national  bureau  of  preven- 
tive medicine.^ 

In  the  Department  of  Agriculture: 

The  Bureau  of  Chemistry,  the  principal  hygienic  function 
of  which  is  the  highly  important  one  of  the  investigation 
of  the  adulteration  of  foods,  drugs  and  liquors,  and  the 
administration  of  the  Federal  Pure  Food  Act. 

The  Bureau  of  Animal  Industry  contains,  among  other 
divisions,  the  Dairy  Division,  which  carries  on  sanitary 
and  economic  investigations  of  the  milk  industry,  and  the 
Meat  Inspection  Division,  which  inspects  meat  entering  into 
interstate  traffic  and  the  slaughterhouses  where  it  is  killed 
and  prepared. 

(The  Bureaus  of  Plant  Industry  and  Entomology  also 
publish  occasional  papers  pertinent  to  public  health.) 

In  the  Department  of  Commerce: 

The  Bureau  of  the  Census  includes  the  Division  of  Vital 
Statistics,  which  collects,  analyzes  and  publishes  statis- 
tics of  population,  births  and  deaths,  for  the  country  as 
a  whole  and  for  its  various  cities,  towns  and  other  civil 
divisions. 

In  the  Department  of  Labor : 

The  Children's  Bureau,  instituted  in  1912,  which  conducts 
investigations  and  disseminates  information  dealing  with 
the  protection  of  child  life,  particularly  as  regards  preven- 
tion of  infant  mortality. 

^  See  Anderson,  "Organization,  Powers,  and  Duties  of  the  U.  S. 
Public  Health  Service  To-day,"  Am.  Jour.  Pub.  Health,  1913,  vol. 
Ill,  no.  9,  p.  845;  also  Wyman  in  Reprint,  no.  49,  from  Pub.  Health 
Rpts.,  19 10. 


56  A  MANUAL  FOR  HEALTH  OFFICERS 

Besides  the  above  the  Medical  Departments  of  the  Army 
and  Navy  carry  on  investigations  and  make  reports  on 
phases  of  preventive  medicine  which  are  not  infrequently 
of  wider  significance  than  their  titles  indicate. 

PROPOSED   NATIONAL  HEALTH   SERVICE 

That  the  Federal  health  conserving  agencies  lack  co- 
ordination, that  the  one  most  approximating  a  national 
health  department  —  the  Public  Health  Service  —  is  under 
the  anomalous  control  of  the  financial  department  of  the 
government,  and  that  others  are  scattered  among  several 
departments  and  bureaus  as  we  have  just  seen  —  these 
facts  are  the  basis  of  a  growing  demand  for  a  unified 
National  Health  Service  to  be  organized  as  a  Department, 
or  at  least  as  a  bureau,  of  the  Federal  Government. 

There  was  at  one  time,  in  fact,  a  National  Board  of 
Health.  It  was  established  by  Congress  in  1879,  just  after 
the  yellow  fever  epidemics  in  the  South,  and  was  author- 
ized to  "  obtain  information  upon  all  matters  affecting  the 
public  health."  This  board  accomplished  much  useful 
sanitary  work  and  started  investigations  in  nearly  every 
department  of  sanitary  work,  but  through  the  failure  of 
Congress  to  continue  appropriations  it  was  allowed  to 
lapse  in  1884.  It  was  created  under  the  stimulus  of  the 
prevailing  epidemics  and  was  dissolved  with  their  passing. 

From  that  time  to  the  present  there  have  been  proposals 
for  the  establishment  of  a  national  public  health  service  in 
the  broadest  sense,  to  embrace  all  of  the  present  agencies, 
correlate  them  and  enlarge  their  scope.  Several  years  ago 
the  project  was  taken  up  by  an  organization  formed  for 
that  particular  purpose  —  the  Committee  of  One  Hundred 
on  National  Health  of  the  American  Association  for  the 
Advancement  of  Science.  The  demands  took  on  a  special 
vigor  with  the  publication  of  Professor  Fisher's  Report  on 
National  Vitality  and  the  introduction  of  the  Owen  Bill 
(first  introduced  in  Congress  in   1910  and  re-introduced 


FEDERAL  HEALTH  AUTHORITIES  57 

each  year  since  then),  and  the  hitl(;r  was  followed  some- 
what later  by  a  detailed  brief  ior  it  in  the  form  of  a  Senate 
Memorial.^ 

There  have  also  been  plans  proposed  other  than  tliat 
contemplated  in  the  Owen  Bill,  and  the  general  object  of 
establishing  a  national  health  department  or  bureau  has 
been  widely  indorsed,  the  indorsers  including  the  American 
Public  Health  Association,  the  American  Medical  Associa- 
tion and  many  other  organizations  and  persons,  private 
and  public.  Organized  efforts  for  this  object  are  now 
carried  on  from  year  to  year. 

In  the  present  agitation  the  true  question  relates  not  so 
much  to  the  nature  of  the  activities  now  carried  on  as  to 
their  coordination.  The  demand  for  a  national  health 
department  should  not  be  taken  to  mean  that  we  have  not, 
aside  from  questions  of  organization,  a  good  national 
health  service,  for  a  very  brief  survey  proves  the  reverse. 
Cartoons,  such  as  have  been  published,  showing  "  Uncle 
Sam  "  spending  millions  on  the  health  of  hogs  and  little 
or  nothing  to  promote  the  health  of  human  beings,  are 
false  and  misleading.  The  difficulty  is  that  the  latter 
class  of  work  is  not  so  obviously  organized  as  the  former; 
being  of  a  more  diverse  character,  it  has  not  yet  been  corre- 

^  See  the  following: 

"Work  of  the  Committee  of  One  Hundred  on  National  Health," 
by  Wm.  Jay  Schieffelin,  Publication  No.  628,  American  Academy  of 
Political  and  Social  Science,  191 1.  (The  Committee  has  offices  at 
105  East  22nd  Street,  New  York  City.) 

Report  on  National  Vitality;  its  Waste  and  Conservation,  prepared 
for  the  National  Conservation  Commission  by  Professor  Irving  Fisher, 
Bulletin  30,  of  the  Committee  of  One  Hundred  on  National  Health 
(Government  Printing  Office,  Washington),  1909. 

Memorial  relating  to  the  Conservation  of  Human  Life  as  contem- 
plated by  Bill  (S.  i)  providing  for  a  United  States  Public  Health  Ser- 
vice, prepared  by  Prof.  Irving  Fisher,  assisted  by  Miss  Emily  F. 
Robbins,  Senate  Document  No.  493,  62nd  Congress,  2nd  Session,  1912. 

(The  latter  two  publications  may  be  obtained  on  application  to  the 
Supt.  of  Documents,  Government  Printing  Office,  Washington.) 


58  A  MANUAL  FOR  HEALTH  OFFICERS 

lated  in  one  department.  Nor  should  the  present  demand 
be  taken  to  signify  that  local  and  state  work  is  being  directly 
held  back  pending  rc-organization  at  Washington.  But 
the  efforts  to  obtain  such  re-organization  and  thus  even 
greater  efficiency  are  evidently  based  upon  sound  arguments, 
and,  when  questions  as  to  the  particular  form  of  re-organ- 
ization shall  have  been  settled,  will  doubtless  gain  the 
desired  end. 


CHAPTER   IV 
UNOFFICIAL    ORGANIZATIONS 

To  complete  our  survey  of  the  public  scheme  we  may 
now  pass  in  brief  review  the  highly  important  work  carried 
on  by  the  numerous  unofificial  organizations  which  in  vari- 
ous ways  are  working  for  the  promotion  of  public  health. 
This  work  is  far-reaching  in  its  influence,  meeting  a  multi- 
tude of  needs  which,  owing  to  the  limitations  in  principle 
or  the  deficiencies  in  practice  of  governmental  organiza- 
tion, are  not  met  by  the  public  authorities. 

Such  organizations  are  not  simply  philanthropic.  Be- 
sides performing  functions  inappropriate  to  public  author- 
ities, it  is  their  indispensable  part  to  take  up  activities 
which  are  as  yet  only  in  the  experimental  or  preexperi- 
mental  stage  and  to  venture  to  test  them  out,  thus  exer- 
cising an  initiative  which  might  be  deemed  unjustified  in 
an  administrative  organization  spending  public  money. 
Eventually,  if  the  enterprise  succeeds  and  a  new  field  for 
public  activity  is  pointed  out,  then  it  may  be  transferred 
to  the  health  authorities  as  a  recognized  department  of 
administration.  Thus  possibilities  are  transformed  first 
into  actualities  and  then  into  permanent  public  functions. 
This  has  been  the  history  of  the  anti-tuberculosis  move- 
ment, for  which  the  relative  amount  of  public  money  spent 
is  increasing  from  year  to  year;  and  it  is  now  the  histor}^ 
in  the  working  out,  of  child  hygiene  work. 

Even  where  the  governmental  functions  are  firmh' 
established,  voluntary  organizations  play  a  useful  part 
through  cooperation.  Recommendations  and  criticisms 
from  such  sources  are   frequently  of  value.     The  health 

59 


6o  A  MANUAL   FOR   HEALTH   OFFICERS 

officer  furthermore  depends  upon  local  organizations  of 
this  kind  to  a  greater  or  less  extent  for  the  spreading  of 
information  and  the  fostering  of  the  public  support  which 
he  needs.  Civic  and  philanthropic  societies  thus  act  as 
mediators  between  health  officer  and  public. 

In  scope,  such  organizations  range  from  the  local  to  the 
national  and  international;  in  object,  they  are  as  diverse 
as  the  multitude  of  subjects  related,  directly  or  indirectly, 
to  the  public  health.  Only  a  summary  of  those  of  chief 
interest  to  the  local  health  officer  can  be  given  here, 

NATIONAL 

The  following  are  related  directly  to  public  health  on  a 
national  scale : 

The  American  Public  Health  Association  is  the  oldest 
and  the  leading  organization  of  the  country  devoted  to  the 
advancement  of  public  hygiene.  It  was  founded  in  1872 
and  draws  its  members  from  the  United  States,  Canada, 
Mexico,  and  Cuba.  Its  aims  are:  "  the  development  and 
advancement  of  public  hygiene;  the  correlation  of  princi- 
ples and  practice;  and  the  promotion  of  public  hygiene  as 
a  distinct  profession."  The  Association  holds  an  annual 
meeting  (varying  the  place  of  meeting  from  year  to  year) 
which  is  the  mecca  of  American  public  health  officials  and 
experts.  ...  It  is  organized  and  meets  for  the  reading 
of  papers  and  discussion  both  as  a  general  association  and 
also  in  the  following  sections:  laboratory,  vital  statistics, 
public  health  officials,  sanitary  engineering,  and  sociology. 
Important  work,  especially  in  the  collection  of  data  and  the 
formulation  of  standards,  is  performed  by  the  committees 
of  the  association.  All  persons  engaged  in  official  or  techni- 
cal work  in  public  health  lines  or  interested  in  public  health 
work  are  eligible  for  membership. 

The  official  organ  of  the  association  is  the  American 
Journal  of  Public  Health,  published  monthly.  The  Journal 
is  a  running  library  on  public  health  work  and  sanitary 


UNOl'TICIAI.   OROANIZA'I  IONS  6l 

engineering,  and  its  volumes  f(jr  conipleLcd  years  ifre  in- 
dispensable works  of  reference  to  the  health  officc.-r.  The 
departments  embraced  are  as  follows:  editorial;  health 
department  reports  and  notes;  public  health  notes;  re- 
cent articles  on  sanitary  science  and  public  health;  papers 
of  American  Public  Health  Association;  industrial  hygiene 
and  sanitation;  personal  notes;  book  reviews;  and  an 
index  of  current  public  health  literature.  Membership  in 
the  Association  and  subscription  to  the  Journal  are  in- 
dispensable to  health  officers  and  other  pul)lic  health 
workers.  Further  information  concerning  both  may  be 
obtained  from  the  Secretary,  755  Boylston  Street,  Boston. 
Subscription,  $3  a  year  (3  months'  trial,  50  cents). 

The  National  Association  for  the  Study  and  Prevention 
of  Tuberculosis,  105  East  22nd  Street,  New  York  City,  acts 
as  a  central  bureau  of  exchange  for  information  regarding 
tuberculosis,  conducts  investigations,  manages  the  sale  of 
Red  Cross  Seals  for  the  tuberculosis  campaign,  publishes 
books  and  pamphlets,  encourages  local  work,  and  has  an 
annual  meeting  the  proceedings  of  which  are  published. 
In  particular,  it  issues  a  monthly  bulletin  for  those  inter- 
ested in  tuberculosis  work  and  publishes  the  Journal  of 
the  Outdoor  Life,  a  monthly  periodical  devoted  to  the  pre- 
vention and  cure  of  tuberculosis. 

The  American  Association  for  Study  and  Prevention  of 
Infant  Mortality,  121 1  Cathedral  Street,  Baltimore,  gathers 
data,  issues  printed  matter,  has  a  traveling  exhibit,  and 
meets  annually,  publishing  its  proceedings  in  an  annual 
volume  of  papers  and  discussions. 

The  National  Housing  Associatioyi,  105  East  22nd  Street, 
New  York  City,  conducts  investigations,  publishes  books 
and  pamphlets,  and  stimulates  the  formation  of  state  and 
local  societies  for  improving  housing  conditions. 

The  American  Medical  Association  has  a  section  de\'oted 
to  Preventive  Medicine  and  Public  Health  and  a  Council 
on  Health  and  Public  Instruction.     In  its  Journal  public 


62  A  MANUAL   IX)R   IlilAL'I'lI   OFFICERS 

health  matters  are  frequently  discussed.  In  1913  the 
Council  called  a  conference  of  representatives  of  the  fifty- 
odd  national  organizations  related  to  public  health  for 
the  purpose  of  forming  a  central  organization  to  correlate 
their  work.  Office  of  the  Association  and  Journal:  535 
North  Dearborn  Street,  Chicago. 

The  Committee  of  One  Hundred  on  National  Health 
has  already  been  mentioned  in  Chapter  HI. 

The  following  is  a  brief  directory  of  some  of  the  other 
organizations  which  enter  directly  or  indirectly  into  the 
field  of  public  health.  These  organizations  collect  data 
and  issue  reports  and  other  literature  and  invite  oppor- 
tunities to  cooperate  and  confer  with  officials  and  others 
desiring  information  or  aid. 

National  Child  Welfare  Exhibition  Committee  (advises 
on  exhibits  and  lends  material  for  same),  200  Fifth  Ave., 
New  York  City. 

American  School  Hygiene  Association ;  Secretary,  Dr.  T. 
A.  Storey,  College  of  the  City  of  New  York,  New  York 
City. 

American  Civic  Association  (fly,  mosquito  and  smoke 
nuisances,  etc.),  Union  Trust  Building,  Washington,  D.  C. 

National  Municipal  League  (ci\'ic  organization,  etc.), 
North  American  Building,  Philadelphia. 

American  Association  for  Labor  Legislation  (publishes 
a  volume  on  industrial  diseases),  131  East  23rd  Street, 
New  York  City. 

American  Social  Hygiene  Association  (sex  hygiene), 
105  West  40th  Street,  New  York  City. 

Society  of  Sanitary  and  Moral  Prophylaxis  (sex  hygiene), 
105  West  40th  Street,  New  York  City. 

American  Society  for  the  Control  of  Cancer  (dissemi- 
nates knowledge  concerning  symptoms,  diagnosis,  treat- 
ment and  prevention),  289  Fourth  Avenue,  New  York 
City. 

National  Organization  for  Public  Health  Nursing  (ob- 


UNOFFICIAL  ORGANIZATIONS  63 

ject:  "  to  stimulate  the  extension  of  pu1;lic  health  nursing, 
to  develop  standards  of  t{;ehni(iiie,  to  maintain  a  central 
bureau  of  inforniation  ";  ])ul)lishes  a  quarterly  and  bulle- 
tins), 54  East  34th  Street,  New  York  City. 

American  Statistical  Association  (publishes  a  Quarterly), 
491  Boylston  Street,  Boston. 

Departments  of  Child-HeljMng  and  for  Prevention  of 
Blindness,  Russell  Sage  Foundation,  130  East  22nd  Street, 
New  York  City. 

Department  of  Surveys  and  Exhibits,  Russell  Sage 
Foundation  (makes  health  surveys  and  examinations  of 
health  department  organizations  and  methods),  130  East 
22nd  Street,  New  York  City.^ 

Bureau  of  Municipal  Research  (makes  examinations  of 
systems  and  efficiency  of  health  and  other  municipal  de- 
partments and  maintains  a  Training  School  for  Public 
Service),  261  Broadway,  New  York  City.^ 

Besides  the  above  there  are  a  number  of  organizations 
dealing  with  special  phases  of  sanitation,  with  civics,  chari- 
ties, medical  research,  and  the  like,  which  cannot  be 
enumerated  here.  (For  treatment  of  such  subjects  see 
the  Survey,  a  weekly  periodical  devoted  to  social  welfare, 
published  at  105  East  22nd  Street,  New  York  City, 
which  occasionally  prints  a  directory  of  such  organizations 
as  mentioned  above.) 

^  In  considering  the  work  of  these  organizations  distinction  should 
be  made  between  a  "survey  of  the  public  health  situation"  (which 
takes  the  figures  readily  available  and  forms  judgments  from  these)  and 
a  thoroughgoing  "  public  health  survey  "  (which  goes  into  local  con- 
ditions in  detail,  making  inspections,  analyses,  special  statistical  studies, 
etc.).  Both  forms  of  survey  have  a  two-fold  scope:  on  the  one  hand 
the  sanitary  conditions  and  problems,  and  on  the  other  hand  the  organ- 
ization and  elificiency  of  the  health  department.  Altogether  the  aim 
of  a  survey  may  be  expressed  as  an  evaluation  of  actual  conditions  with 
recommendations  for  necessary  improvements.  Both  of  the  abo\"e  or- 
ganizations publish  reports  of  the  surveys  which  they  have  made  in 
various  towns  and  cities,  which  may  be  obtained  on  application. 


64  A  MANUAL   FOR   HEALTH  OFFICERS 

Auxiliary  Public  Health  Movements.  —  We  must  note  a 
nunilx-r  of  auxiliary  movements  which  contribute  directly 
to  the  general  public  health  movement.  There  is,  for 
example,  the  recent  action  of  some  life  insurance  companies 
in  educating  policy-holders  in  hygienic  precautions,  in 
pro\'iding  visiting  nurse  service  for  policy-holders,  and  in 
endeavoring  to  obtain  improvement  of  sanitary  condi- 
tions and  administration. 

Then  there  is  the  movement  of  the  employers,  who  are 
voluntarily  paying  increased  attention  to  the  hygiene  of 
factories  and  labor. 

There  is,  furthermore,  a  movement  on  the  part  of  em- 
ployees themselves.  Trades  organizations  of  all  kinds  are 
taking  an  interest  in  the  hygienic  problems  of  their  partic- 
ular trades.  Such  organizations  play  an  important  part 
in  furthering  compliance  with  health-protective  measures 
in  factories  by  imposing  upon  their  members  health  rules 
(e.g.,  forbidding  improper  spitting)  and  by  arranging  for 
talks  to  their  members  on  prevention  of  disease. 

Again,  there  are  trade  organizations  aiming  at  economical 
conformance  with  sanitary  rules  and  at  securing  recogni- 
tion of  sanitary  trade  standards;  of  such  the  New  York 
Sanitary  Milk  Dealers'  Association  is  an  example. 

The  certified  milk  movement,  started  a  number  of  years 
ago  (by  physicians,  however,  and  without  any  commercial 
object),  with  the  object  of  obtaining  and  marketing  under 
legal  protection  a  high  grade  of  milk  is  an  excellent  example 
of  cooperation  of  physician,  sanitarian  and  dealer. 

The  latest  phase  of  the  publicity  movement  is  now  to  be 
seen  in  the  establishment  of  more  or  less  permanent  ex- 
hibits or  museums  of  hygiene.  Thus  the  American  Museum 
of  Natural  History,  at  New  York,  has  developed  a  depart- 
ment of  sanitary  exhibits,  together  with  a  central  exchange 
bureau  for  bacteria  cultures.  The  New  York  City  Depart- 
ment of  Health  maintains  a  permanent  exhibit  illustrating 
its  work. 


UNOI'I'ICIAI.  ()k(;ANI/Arif)NS  65 

International  Organizations.  —  Finally,  rapping  llic  jxihlic 
health  scheme,  there  arc  various  international  associations 
and  congresses,  dealing  with  tuberculosis  and  other  branches 
of  public  hygiene  and  dominated  by  the  Inlernatinnal 
Congresses  on  Hygiene  and  Demography.  The  latter  are 
held  at  intervals  of  from  three  to  five  years  and  always  on 
the  invitation  of  a  national  government,  and  give  occasion 
for  the  greatest  gatherings  of  hygienists  in  the  world. 
The  fifteenth  Congress,  for  which  over  3300  members 
were  registered,  was  held  in  Washington  in  1912.  An  ex- 
tensive exhibition  was  held  in  connection  with  the  Con- 
gress. Besides  general  lectures  by  men  of  eminence  510 
papers  were  presented  before  the  nine  sections,  treating  of 
all  branches  of  science  and  practice  in  personal  and  public 
hygiene.  The  papers  and  resultant  discussions  are  pub- 
lished in  a  set  of  transactions  which  constitutes  a  veritable 
library  on  those  subjects.^ 

STATE 

Among  non-governmental  state  organizations  we  may 
mention  first  the  health  officers'  associations  which  are  be- 
ginning to  spring  up  in  various  states  and  which  evidently 
fill  so  fundamental  a  need  that  doubtless  there  will  soon 
be  no  state  without  one.  Such  associations,  while  perhaps 
nominally  open  to  members  of  boards  of  health,  are  pri- 
marily for  the  executive  officer.  The  objects  aimed  at  are 
stated  in  the  constitution  of  one  of  these  associations  as 
"  the  advancement  of  knowledge  relating  to  public  health 
and  sanitation  and  the  encouragement  of  social  intercourse 
among  health  board  officials."  These  objects  are  ful- 
filled by: 

(i)  Presentation  of  papers  and  discussion,  which  may 
be  of  a  more  local  and  informal  character  than  in  national 

^  Trans.  XV  Internal.  Congress  Hyg.  and  Demogr.,  8  vols.,  Govern- 
ment Printing  Office,  Washington,  D.  C,  1913. 


66  A   MANUAL   1X)R    HEALTH   OFFICERS 

organizations,  and  hence  of  a  peculiar  value  to  the  mem- 
bers. 

(2)  Improvement  and  standardization  of  methods,  pro- 
cedures and  forms  (for  records,  reports,  etc.),  particularly 
as  related  to  state  laws  and  conditions. 

(3)  Formation  and  securing  of  needed  state  legislation. 

(4)  Raising  the  standards  of  administration  through  pro- 
fessional improvement  of  the  members  and  maintenance 
of  a  reasonably  high  standard  for  membership. 

(5)  Promoting  useful  as  well  as  agreeable  social  inter- 
course among  health  officials,  both  state  and  local. 

(6)  Cooperation  with  the  state  department  of  health,  in 
every  way  promoting  more  effective  relationship  between 
state  and  local  departments  and  officers. 

Meetings  of  state  associations  may  be  successfully  held 
four  or  five  times  a  year,  a  program  of  a  fciu  important 
topics  with  one  or  two  leading  speakers  being  arranged  for 
each  meeting.  One  of  these  meetings  may  well  consist  in 
an  annual  conference  of  state  and  local  health  authorities 
held  at  the  state  capital,  with  a  more  extensive  program 
and  committee  reports. 

An  active  executive  committee  (which  may  act  as  a 
committee  on  program,  resolutions  and  the  like)  is  a  prime 
necessity,  as  is  also  an  enterprising  membership  committee 
with  members  working  in  all  parts  of  the  state.  A  few 
small  committees  on  legislation,  vital  statistics,  communi- 
cable disease,  food  and  drugs,  etc.,  are  advisable.  The 
plan  of  organization  should  be  simple  and  the  rules  as  few 
as  possible.  There  should  be  a  provision  of  state  law 
that  local  boards  of  health  defray  the  necessary  expenses 
of  their  executive  officers  in  attendance  at  meetings.^ 

'  Further  information  regarding  the  organization  of  health  officers' 
associations  may  be  obtained  through  the  state  departments  of  health 
in  those  states  where  such  associations  have  I^een  formed:  Massachu- 
setts, New  York,  New  Jersey,  North  Carolina,  Connecticut,  Michi- 
gan, etc. 


UNOFFICIAL  ORCiANIZyVnONS  67 

In  addition  to  the  class  of  associations  just  discussed 
may  be  mentioned  the  state  medical  societies,  sanitary 
associations,  civic  societies,  anti-tuberculosis  societies,  and 
the  like,  which  touch  directly  ov  incjirectly  public  health 
matters,  and  in  which,  according  to  circumstances,  the 
health  officer  may  or  may  not  take  an  active  part. 

LOCAL 

Cooperation  with  local  organizations  bearing  on  public 
health  or  civics  is  one  of  the  important  phases  of  the  work 
of  the  health  officer.  Such  organizations  are  frequently 
of  much  value  in  that  they  perform,  or  at  least  assist  in, 
work  which  the  health  department  has  not  resources  and 
authority  to  carry  on  alone.  This  applies  especially  to 
local  societies  engaged  in  tuberculosis  and  infant  hygiene 
work  of  any  kind.  There  may  also  be  advantages  in  co- 
operating with  the  local  bureau  of  organized  charities  and 
with  the  dispensaries  and  social  service  departments  of 
hospitals.  Where  the  inter-relations  are  extensive  a  scheme 
of  "  cooperation  without  amalgamation  "  should  be  defi- 
nitely worked  out,  so  that  those  social  activities  directly 
affecting  public  health  may  be  properly  correlated.  By 
such  a  scheme,  in  detail,  all  the  persons  and  organizations 
concerned  may  know  exactly  their  relations  to  one  another. 
It  scarcely  need  be  said  that  it  is  the  health  officer  who 
should  take  the  initiative  and  leadership  in  this  broader 
phase  of  public  health  organization. 

It  is  the  part  of  wisdom  to  win  the  good  will  of  civic 
clubs,  women's  clubs,  local  improvement  societies,  and 
the  like.  Such  organizations,  for  example,  frequently  may 
arrange  and  advertise  "  clean-up  "  days  or  weeks  which 
save  the  health  department  a  great  deal  of  routine  inspec- 
tion and  notification  and  help  to  reduce  the  rubbish,  fly 
and  mosquito  nuisances;  may  arrange  for  civic  exhibits; 
and  so  forth.  More  important  still,  such  organizations 
offer  forums  of  discussion  of  civic  health  matters  which 


68  A  MANUAL   FOR   HEALTH  OFFICERS 

are  of  material  assistance  in  the  publicity  campaign.  The 
support  of  boards  of  trade  and  other  business  organizations 
whose  membership  includes  influential  citizens  should  be 
obtained,  and  the  value  of  public  health  as  a  fundamental 
factor  in  prosperity  should  be  impressed  upon  them. 

In  conclusion  it  may  be  said  that  the  public  health  move- 
ment involves  numerous  inter-relationships,  into  which 
the  health  officer,  without  dissipating  his  energy,  will 
enter  just  to  the  extent  necessary  most  effectively  to  further 
his  aims.     This  will  vary  according  to  circumstances. 


CHAPTER   V 

THE   NEW   PUBLIC   HEALTH 

THE   SCIENCE   OF   PUBLIC   HEALTH 

The  importance  of  hygiene  among  the  sciences  and  of 
sanitation  among  the  practical  arts  is  unquestioned. 
Health  has  ever  been  recognized' as  the  chief  basis  for  wealth 
and  happiness  and  in  this  age  is  the  subject  of  a  science  and 
administrative  practice  of  its  own.  Hence  we  find  the 
statesman  Disraeli  affirming  that  "  the  care  of  the  public 
health  is  the  first  duty  of  the  statesman." 

Public  health  matters  until  recent  decades  lay  largely 
in  the  realms  of  speculation  and  crude  empirical  knowledge. 
Such  was  the  case  until  the  development  of  physics  and 
chemistry  paved  the  way  for  the  modern  science  of  biology, 
of  which  hygiology,  or  sanitary  science,  is  one  grand  divi- 
sion. Although  it  is  the  youngest  of  the  physical  sciences, 
biology  has  grown  apace  and  the  sum  of  hygienic  knowledge 
has  so  developed  that  if  it  were  now  thoroughly  applied 
to  the  conditions  of  human  life  there  would  result  a  won- 
derful amelioration.  Application  of  the  knowledge  we  al- 
ready possess  is  perhaps  a  greater  need  of  the  time  than 
the  further  extension  of  that  knowledge. 

This  is  not  the  place  for  an  exhaustive  treatment  of  the 
principles  of  sanitary  science,  which,  as  the  foundation  of 
all  sound  sanitary  practice,  are  in  this  volume  for  the  most 
part  taken  for  granted.  They  will  be  found  treated  at 
length  in  various  other  works.  A  brief  review  of  funda- 
mental considerations  must  serve  as  introduction. 

69 


70  A  MANUAL  FOR  HEALTH  OFFICERS 

The  student  of  hygiene  is  concerned  with  those  condi- 
tions which  prevent  the  body  —  that  wonderful  "  physical 
mechanism  "  (as  it  is  called  by  Huxley)  —  from  running  a 
nomial  course  in  health  from  birth  to  old  age.  Strictly 
speaking  "  senility,"  or  old  age,  is  the  only  natural  death, 
but  a  glance  at  the  mortality  tables,  as  we  shall  see  pres- 
ently, shows  that  it  is  the  given  cause  in  v^ery  few  cases, 
and  that  in  the  great  majority  of  cases  death  is  really 
premature. 

The  conditions  which  cut  down  many  lives  in  length,  or 
efficiency,  or  both,  and  cause  premature  old  age,  debility 
or  death,  are  of  three  classes:  (i)  defects  and  weaknesses 
in  the  physical  mechanism,  i.e.,  constitutional  handicaps; 
(2)  abuses  in  the  care  of  it  by  the  owner  —  matters  of 
personal  hygiene;  and  (3)  unfavorable  environmental 
conditions.  It  is  with  the  last-named  —  the  control  of  the 
environmental  factors  through  public  hygiene  —  that 
health  authorities  are  concerned. 

Definitions.  —  We  may  now  set  down  several  convenient 
definitions.  General  hygiene,  or  simply  "  hygiene,"  is  "  the 
whole  science  and  art  of  the  conservation  and  promotion 
of  health  both  in  individuals  and  in  communities  "  (Sedg- 
wick).    General  hygiene  is  subdivided  into: 

Public  hygiene,  the  care  of  the  health  of  communities  by 
public  authorities;   and 

Persofial  hygiene,  the  care  of  the  health  of  individuals 
by  themselves. 

Practically  the  two  classes  of  hygiene  merge  into  each 
other. 

Sanitary  science,  or  public  health  science,  is  the  body  of 
scientific  principles  governing  public  hygiene.  (The  term 
"preventive  medicine"  is  also  —  less  accurately  —  used 
in  the  same  sense.)  Those  principles  are  practically  ap- 
plied through  sanitation,  which  includes  all  the  sanitary 
arts,  such  as  sanitary  engineering,  the  various  branches  of 
municipal  sanitation  and  administration,  and  the  like. 


THE  NEW   PUBLIC   ilEAL'lJI  7 1 

It  is  with  the  art  of  practical  sanitary  administration 
that  the  present  volume  is  concerned. 

The  loose  use  of  the  word  "  sanitary  "  to  denote  merely 
cleanliness,  aljscnce  of  offence,  and  the  like  —  as  in  "  sani- 
tary plumbing,"  "  sanitary  garbage  cans,"  etc.  —  should 
be  avoided.  v 

THE   PROBLEMS   OF   PUBLIC   HEALTH 

Statistical  Survey  of  the  Problem  of  Prevention.  —  Vital 

statistics  (whicli  will  be  discussed  in  the  chapter  on  that 
subject)  furnish  the  means  by  which  problems  of  mortality 
and  the  prevention  of  sickness  and  death  may  be  accurately 
gauged.  For  figures  of  a  general  nature  we  turn  to  the 
Mortality  Statistics  of  the  United  States  Census  Bureau, 
from  which  the  citations  in  this  section  are  made. 

The  most  general  index  of  mortality  in  any  population 
is  the  annual  death  rate.  That  rate  for  the  Registration 
Area  of  the  United  States  in  1913  was  14. i  per  thousand 
of  population.  The  figure  is  on  the  decline,  being  for 
previous  years  as  follows:  1890,  19.6;  1900,  17.6;  1905, 
16.0;  1910,  15.0;  1911,  14.2;  1912,  13.9.  The  rate  14. i 
(or  the  corresponding  figure  for  later  years)  is  a  convenient 
one  to  remember,  representing,  as  it  does,  the  average 
death-rate  of  a  group  constituting  three-fifths  of  the  popu- 
lation of  the  United  States  at  the  present  time;  it  is  the 
most  nearly  representative  National  death  rate  that  we 
have.  It  strikes  an  average  among  all  kinds  of  commu- 
nities and  between  extremes  of  healthfulness  and  unhealth- 
fulness.  In  the  rural  ^  part  of  the  Registration  States  the 
rate  in  1913  was  12.7,  but  in  the  cities  of  those  States, 
where  urban  congestion  and  unsanitary  factors  make  them- 
selves greatly  felt,  it  was  15.0.  The  rates  for  the  largest 
Registration  Cities  ranged  for  1913  from  8.4  to  20.8,  many 
of  the  variances  being  explicable  by  differences  in  popula- 

^  From  1900  to  1909  the  Census  classified  as  rural  places  with  a  popu- 
lation of  less  than  8,000  and  since  1910  those  under  10,000. 


72  A   MANUAL   FOR   HEALTH  OFFICERS 

tion  characteristics  as  well  as  in  sanitation  (a  consideration 
which  will  be  explained  later  on  in  the  chapter  on  Vital 
Statistics).  For  the  individual  Registration  States  that 
year  the  rates  ranged  from  8.5  to  17.1. 

But  such  general  rates  tell  us  nothing  as  to  premature 
and  preventable  mortality.  To  gain  such  knowledge  the 
general,  or  total,  mortality  must  be  analyzed  into  its  chief 
components. 

The  extent  of  premature  mortality  may  be  roughly 
gauged,  for  example,  by  a  study  of  the  ages  at  time  of  death. 
The  fact  that  the  average  age  at  death  in  the  Registration 
Area  in  1913  was  39.8  years  indicates,  though  crudely,  that 
many  individuals  fail  to  reach  the  traditional  age  of  "  three- 
score years  and  ten."  Further  study  shows  that  the  death 
toll  on  infants  is  especially  heavy.  This  constitutes  the 
important  problem  of  infant  mortality.  Thus  in  the 
Registration  Area  in  191 3,  25  per  cent  of  all  deaths  occurred 
under  five  years  and  18  per  cent  under  one  year  of  age. 
(Table  I  and  Chart  i  indicate  the  incidence  of  mortality 
on  the  population  groups  of  various  ages;  showing  the 
high  infant  death  rate,  the  minimum  rate  at  the  age  of 
10  to  15  years,  and,  finally,  the  increasing  mortality  in 
later  life  reaching  a  maximum  again  at  the  most  advanced 
ages.) 

Now  that  it  is  evident  that  the  great  majority  of 
deaths  occur  at  ages  which  must  be  considered  premature, 
the  all-important  question  for  the  sanitarian  is:  How 
many,  and  which  of  these  deaths  are  practically  preventable 
through  public  hygiene  ?  This  leads  to  a  consideration  of 
causes  of  death. 


THE   NEW    PUIiMC   JIJOALTJI 


73 


TABLE   I 

Mortality  According  to  Age 

Population,  deaths,  and  specific  death  rates,  by  age  periods,  for 
the  U.  S.  Registration  States,'  1911.  (Figures  furnished  Ijy  courtesy 
of  the  Bureau  of  the  Census.) 


Age  group 


All  ages. 


Under  i  year. 
I  to  5  years. 


Under  5  years. 
5  to  ID  years. 
10  to  15  years. 
15  to  20  years. 
20  to  25  years. 
25  to  35  years. 
35  to  45  years. 
45  to  55  years. 
SS  to  65  years. 
65  to  75  years. 
75  and  over. . . 


Unknown  age' 


Population 


54,010,920 

1,183,384 
4,468,804 

5,652,188 
5-166,113 

4,935,04s 
5,098,472 
5,296,929 
9,270,326 
7,409,542 
5,363,885 
3,220,105 
1,832,530 
765,785 


Deaths' 


Number 


749,918 

133-636 
52,553 

186,189 

15,973 
10,898 
18,370 
27,586 
59,079 
65,896 
73,040 
84,226 
101,101 
106,352 

1,208 


Rate  per  looo 

population  of 

corresponding 

age 


139 


112  .9 
II. 8 


32. 
3- 
2. 

3- 
5- 
6. 


138.9 


•  Includes  District  of  Columbia,  but  excludes  North  Carolina. 

2  Exclusive  of  stillbirths. 

'  Unknown  age  not  distributed. 


In  the  first  place,  in  Chart  i  the  chief  preventable  causes 
of  death  at  the  various  ages  are  roughly  indicated  by  the 
lettered  brackets,  as  follows: 

A.  Infant  mortality  (various  causes). 

B.  Communicable  diseases  of  childhood. 

C.  Tuberculosis  and  typhoid  fever. 

In  addition,  there  are  also  given,  though  not  directly  sub- 
ject to  public  health  administration: 


74 


A  MANUAL  FOR  HEALTH  OFFICERS 


D.  Premature  degeneration  of  circulatory,  urinary,  and 
other  systems,  and  various  constitutional  causes;   and 

E.  Advancing  debility  of  old  age. 

Under  the  last  two  heads  it  must  be  remembered,  however, 
that  death  is  actually  due  to  (and  should  be  set  down  to) 
specific  causes  favored  or  brought  on  by  the  degeneration, 

Chart  i.    Death  Rates  by  Ages 

U.  S.  Registration  States,  191 1.     (Based  on  Table  I.)     For 

explanation  of  "  A,"  "  B,"  etc.,  see  te.xt 

l;>0 

o 
ts 

-no 

c 
'■5  100 


80 


•>   60 


50 


h   40 


S   30 

"S 
tf   20 


«  10 


1.) 

ana 

over 

VS6. 

7 

1 

j|ll2 

'J 

/ 

1 

/ 

/ 

/ 

/ 

; 

i55.2 

/ 

/ 

/ 

A^.i 

All 

Ages 

:13.9 

^ 

/> 

k 

1.8 

^ 

''i:i,r. 

\ 

^ 

2.2 

•3.C 

5.2 

■ " 

^gT 

*t.9 

gl     . 

> 10      y,     20     2.5     30     3r>     40      4.J      50     ;Vj     (jO      iiT,     70      75     80 

Ages  '-' 

constitutional  defect,  or  debility.  The  practice  of  vital 
statistics  prescribes  that  the  specific  cause  rather  than  the 
general  condition  be  used  in  describing  deaths.  Also, 
the  distribution  is  by  no  means  as  exact  as  indicated  in 
the  chart,  which  is  in  this  respect  only  roughly  illustrative, 
and  no  note  is  made  of  the  environmental  conditions  which 
affect  all  ages. 

In  further  analysis  there  are  shown  in  Table  II  and  Chart 
2  the  death  rates  in  the  Registration  Area,  for  1906-1910, 
for  certain  specific  causes  of  death. 


THE   NKW    PUBLIC   IIKALTJI 


75 


TABLE   II 


Death  Rates  uy  Cause 

Registration  Area  of  the  United  States:  Annual  Averages,  1906- 
1910  inclusive.  (From  U.  S.  Mortality  Statistics  for  191 1,  Bureau 
of  the  Census.)  Stillbirths  not  included.  For  explanation  of  the 
table,  see  the  text. 

Specially  noteworthy  preventable  causes  (see  p.  77)  in  heavy-faced 
type. 

Titles  in  brackets  [  ]  are  disapproved  by  the  Census  Bureau  as 
indefinite  or  otherwise  undesirable,  though  necessarily  retained  for 
the  present. 


28-35 


79 
92 

91 

104 

120 

39-45 

64 
151 


150 
154 


All  causes 

Tuberculosis  (total) 

Of  the  lungs 146 . 8 

Tuberculous  meningitis 9.1 

Abdominal  tuberculosis 6.0 

Pott's  disease  (tub.  of  spine) 1.5 

[White  swellings]  (tub.  of  joints) 0.7 

Other  organs- 2.1 

Disseminated  tuberculosis 2.5 

Organic  diseases  of  the  heart 

Pneumonia  (total) 

Bronchopneumonia 

Diarrhoea  and  Enteritis   (under  2  years)  . . . 

Bright's  disease 

Cancer    (and     other    malignant     tumors) 

(total) 

Cerebral  hemorrhage,  apoplexy 

[Congenital  debility],  icterus,  and  sclerema 
(including  premature  birth  but  not  still- 
birth)   

Congenital  malformations    (stillbirths  not 

included) 

[Senility  (old  age)] 


1511-5 
169 


^33 

103 

40 

96 

87 

73 
72 


64-S 

14.9 
29 


1  According  to  Detailed  International  List. 

2  For  recent  years  acute  miliary  tuberculosis  is  given  separately  by  the  Census;  figures 
not  available  for  1906-10. 


76 


A   MANUAL   FOR   HEALTH   OFFICERS 


Nos.i 


9 

lO 

8 
6 

7 
14 
37 
i8 

20 
24 

4 
63  (in 
part) 

13 

61  (in 
part) 
38 
5 

19 
23 
26 

57 
58 
59 
25 


Cause 


Typhoid  fever 

Diphtheria  [and  croup] 

Influenza 

Whooping  cough  

Measles 

Scarlet  fever 

Dysentery  (amebic,  bacillary) 

Syphilis 

Erysipelas 

Purulent  infection  and  septicemia 

Tetanus 

Malaria 

Acute    anterior    poliomyelitis    [infantile 

alysis  ]  ^ 

[Cholera  nostras] 

Cerebrospinal  fever  (epidemic  cerebrospinal 

meningitis) 

Gonococcus  infection 

Smallpox 

Other  epidemic  diseases 

Rabies 

Pellagra^ 

Chronic  lead  poisoning 

Other  chronic  occupational  poisonings 

Other  chronic  poisonings 

Mycoses 


par- 


Death  rate  per 
100,000  of 
population 


25.6 
22.4 
16.4 

10.8 

10.6 
6-5 
5-4 
4.2 
3-8 
2.7 
2.6 


1 .0 

0.9^ 

0-3 
0.2 
0.36 
0.2 


0.1 


'  Transmission  of  ac.  ant.  poliomyelitis  not  well  understood,  that  of  pellagra  undeter- 
mined. 

*  1911  only. 

'  The  following  communicable  causes  not  included  under  "  other  epidemic  diseases  " 
had  a  rate  of  less  than  one-tenth  of  i  per  100,000:  —  typhus  fever,  relapsing  fever,  miliary 
fever,  plague,  yellow  fever,  leprosy,  glanders,  anthrax,  "  other  chronic  occupational 
poisonings."     There  were  no  deaths  from  Asiatic  cholera. 

Chart  2.     Death  Rates  for  Chief  Preventable  Diseases 

U.  S.  Registration  Area,  average  annual  rates  per  100,000  population, 

1906-1910.     (Based  on  Table  II.) 

TUBERCULOSIS 


PNEUMONIA  AND  BRONCHOPNEUMONIA 


'143 


DIARRHOEA  AND  ENTERITIS 


UNDER  T^- 
TYPHOID 


5  YEARS 

-26 
^22 


SCARLET 
FEVER 


11.0 
11 
11 
-21 


■96 


X  Syphilis,  malaria,  dysentery,  tetanus,  ac.  ant. 
poliomyelitis,  smallpox,  cerebrospinal  fever, 
"other  epidemic  diseases,"  rabies,  gonococcus 
infection,  chronic  lead  poisoning.  For  other  dis- 
eases see  table. 


THK   NKVV    I'Um.IC    HKAI/lff  77 

This  tabic  includes  those  causes  of  death  having  a  rate 
of  over  50  (omitting  the  group  of  "accidental  or  undefined" 
causes),  senility,  and  all  the  communicable  diseases.  In 
the  chart  only  the  figures  for  the  chief  preventable  diseases 
are  given.' 

The  term  "  preventable  "  is  used  here  and  in  general 
throughout  this  volume  to  denote  that  the  disease  is  wholly 
or  in  considerable  part  preventable  through  practicable 
public  health  measures,  thus  leaving  out  of  present  consider- 
ation heredity,  personal  hygiene  and  prophylaxis,  and  other 
factors  not  dealt  with  directly  by  the  public  health  official. 
Even  so,  the  designation  requires  qualification  in  some 
instances.  Thus,  under  pneumonia,  those  deaths  which 
occur  in  infancy  (about  one-third)  are  largely  preventable 
through  infant  hygiene  work,  while  the  remainder  are  only 
indirectly  and  difficultly  preventable,  so  far  as  public  health 
practice  has  thus  far  shown  (see,  however,  discussion  under 
Pneumonia,  Part  II,  Chapter  I).  Even  among  those 
causes  which  may  more  freely  be  termed  preventable  there 
are  vast  differences  in  the  degree  of  preventability.     Malaria 

1  The  last  bar  on  the  chart  represents  collectively  the  smaller  figures, 
some  of  which  require  comment.  Thus,  the  figure  for  rabies  is  proba- 
bly somewhat  in  deficiency  of  the  truth  on  account  of  non-recognition 
of  some  of  the  deaths  from  this  cause,  and  at  any  rate  does  not  ade- 
quately indicate  the  importance  of  this  absolutely  preventable  disease. 
Nor  is  the  potential  danger  of  smallpox  shown  in  its  present  low  death- 
rate.  Regarding  syphilis  and  gonococcus  infection,  the  figures  are 
again  deficient.  Most  of  the  effects  of  venereal  disease  appear  under 
forms  the  venereal  origin  of  which  is  not  often  mentioned  in  the  death 
certificate.  The  venereal  diseases  constitute  a  problem  of  preventive 
medicine  of  great  magnitude  and  of  extreme  practical  difiiculty,  in  spite 
of  which,  however,  some  of  the  most  advanced  health  authorities  are 
taking  administrative  measures  against  them.  The  term  "  dysentery  " 
is  unsatisfactory,  doubtless  including  a  certain  number  of  deaths  which 
should  properly  be  put  down  to  "  diarrhoea  and  enteritis."  (For  dis- 
cussion of  the  errors  to  which  the  various  terms  are  subject,  see  Part  II, 
Chap.  IX.)  In  general,  it  must  be  added,  the  importance  of  a  cause 
depends  not  only  upon  the  amount  of  mortality  produced  by  it  but 
also  upon  the  degree  to  which  that  mortality  may  be  prevented. 


78  A  MANUAL   FOR   HEALTH  OFFICERS 

and  smallpox  could  readily  be  wiped  out  by  the  thorough 
application  of  practical  measures  now  known,  and  the 
same  may  be  said  of  typhoid,  with  the  exception  of  a  stub- 
born "  residual,"  but  scarlet  fever  and  diphtheria  present 
deeper  and  less  soluble  problems.  In  tuberculosis  and  in 
infant  mortality  (due  to  pneumonia,  diarrhoea  and  enteritis, 
and  other  causes)  the  reduction  process,  though  clearly 
indicated,  is  especially  complicated  by  considerations  of 
personal  hygiene  and  will,  it  appears,  even  under  the  best 
conditions  be  long  and  gradual.  In  measles  and  whoop- 
ing-cough, the  extent  of  practical  prevention  has  thus  far 
proved  slight. 

The  effects  of  the  communicable  diseases  on  mortality 
are  probably  greater  than  is  supposed  even  by  students 
of  mortality  returns.  The  damage  to  vitality  even  in  the 
non-fatal  cases  is  doubtless  a  potent  predisposing  influence 
which  aids  in  swelling  the  list  of  deaths  from  other  causes. 
Such  deaths,  while  frequently  not  ascribed  in  any  degree 
to  any  of  the  communicable  diseases,  nevertheless  may  be 
due  in  part  —  in  many  cases  in  great  part  —  to  the  effects 
of  previous  disease  of  the  communicable  class.  It  has,  for 
instance,  lately  been  shown  by  Woodruff  ^  that  typhoid 
predisposes  to  tuberculosis;  and  if  to  tuberculosis  why 
not  to  diseases  of  the  constitutional  class?  (Tuberculosis 
itself  may,  indeed,  be  considered  as  virtually  a  constitu- 
tional disease,  being  so  widespread  as  to  attack  almost 
anyone  whose  vital  resistance  falls  below  the  safe  limit.) 
Even  with  the  "  minor  "  contagious  diseases,  there  is 
evidence  that  these  tend  to  permanently  injure  the  heart, 
kidneys,  and  other  vital  organs,  so  that  their  effects  may 
be  felt  years  afterwards,  in  middle  life. 

The  health  official  has  to  consider,  not  only  actual,  de- 
monstrable, directmortaVity  from  the  communicable  diseases, 
but  also  their  indirect  contributions  to  the  mortality  from 

*  Woodruff,  "Tuberculosis  Following  Typhoid  Fever,"  Am.  Medi- 
cine, 1914,  N.  S.,  vol.  XI,  no.  I,  p.  17. 


THE   NEW    PUBLIC    HEALTH  79 

other  diseases,  and,  furthcrniore,  the  immense  and  incal- 
culable amount  of  pain,  inconvenience  and  expense  caused 
by  the  sickness  from  communicable  causes. 

Prevention  is  Relative.  —  "  Prevention  "  under  present 
conditions,  is  a  relative,  not  an  absolute  term.  Many 
diseases  may  be  reduced,  but  few  absolutely  prevented. 
While  the  term  "  preventable  "  tends  to  a  justifiable 
optimism,  it  might,  nevertheless,  be  prefcral)le  that  in  scien- 
tific language  we  speak  rather  of  "  reducible  "  diseases. 

It  is  on  account  of  their  preventability,  or  reducibility, 
that  such  diseases,  no  matter  what  their  rates,  are  included 
in  the  table  and  chart.  For,  no  matter  what  the  general 
death  rate  and  specific  death-rates  may  be,  the  work  of 
the  sanitarian  and  health  officer  regards  specifically  the 
possibilities  of  prevention. 

Diseases  not  Subject  to  Public  Health  Measures.  — 
The  remaining  causes  of  death  in  Table  II  are  of  the  class 
of  constitutional  or  environmental  causes  which  are  prac- 
tically uncontrollable  or  subject  to  control  only  or  chiefly 
through  personal  hygiene. 

Organic  diseases  of  the  heart,  Bright's  disease,  and  cere- 
bral haemorrhage  and  apoplexy  are  largely  manifestations 
of  those  degenerations  or  defects  of  the  circulatory  and 
urinary  systems  which  can  be  retarded  or  compensated  for 
only  by  the  hygiene  of  private  life,  —  though  even  here,  as 
we  have  already  shown,  there  is  an  indirect  effect  of  cer- 
tain communicable  diseases  of  childhood  and  adult  life. 

Congenital  malformation  and  debility  are  great  causes 
of  infant  deaths  toward  the  prevention  of  which  little  has 
been  accomplished;  the  reduction  of  venereal  disease, 
with  other  measures,  however,  promises  some  progress  in 
this  direction. 

Cancer  is  a  disease  which  is  apparently  on  the  increase, 
possibly  because  of  the  greater  number  of  persons  surviving 
to  reach  the  cancer  age  of  late  middle  life;  the  researches 
now  being  carried  on  give  hope  that  the  cause  and  means 


So  A  MANUAL   FOR  HEALTH  OFFICERS 

of  prevention  and  cure  may  be  ascertained  in  the  near 
future. 

Influenza  is  a  communicable  disease  the  spread  of  which 
may  be  reduced  through  home  isolation  and  personal 
prophylaxis,  but  which  is  impracticable  of  attack  by  public 
health  authorities;  thus,  it  is  in  the  same  class  as  pneu- 
monia, measles  and  whooping-cough,  although  with  these 
last  two,  on  account  of  their  prevalence  among  school- 
children, reports  from  physicians  are  required  and  some 
attempt  made  at  quarantine. 

The  comparatively  low  position  in  the  list  of  "  senility," 
or  old  age,  the  only  strictly  natural  cause  of  death,  is  inter- 
esting to  note  and  it  would  probably  stand  considerably 
lower  if,  in  all  cases,  the  disease  actually  causing  death 
were  stated  rather  than  the  general  term  "  old  age."  At 
any  rate  the  term  is,  from  a  statistical  standpoint,  unsatis- 
factory. It  would  appear  from  statistical  study  that 
while  old  age  is  a  contributory,  or  predisposing,  cause  of 
death  in  many  cases  and  the  main  cause  in  many  others, 
it  is  the  sole  cause  in  very,  very  few.  Thus,  it  should  be 
regarded,  not  as  a  specific  cause  of  death,  but  rather  as  a 
condition  potently  favoring  mortality. 

Fundamental  Needs.  —  Reasonable  purity  of  air,  water, 
and  food  and  freedom  from  communicable  disease  have 
from  ancient  times  been  the  great  sanitary  desiderata  of 
the  human  race.  They  are  evidently  the  fundamental 
requirements  in  any  stage  of  society.  The  complex  sani- 
tary needs  of  today  spring  from  these  great  roots,  affect- 
ing not  merely  individuals  or  small  groups,  but  very 
frequently  the  whole  community,  for  which  reason  they  are 
the  subjects  of  public  rather  than  of  personal  hygiene. 
While  the  individuals  of  the  family  may  regulate  their 
manner  of  eating,  sleeping,  and  the  like,  with  comparatively 
little  reference  to  the  conduct  of  others,  they  cannot  so 
regulate  the  quality  of  the  air,  water,  and  food  which  they 
consume,  nor  can  they  assure  themselves  of  freedom  from 


THE   NF'IW    PUniJC   IIKALTII  8 1 

the  communicable  diseases  of  their  neighbors.  The  air 
which  the  citizen  breathes  may  be  that  of  the  common 
atmosphere  of  the  factory,  the  water  and  the  frxxl  which 
he  consumes  may  be  drawn  from  common  pubUc  supplies 
far  beyond  his  inspection  or  even  knowledge. 

The  more  complex  the  civilization  the  greater  are  the 
sanitary  needs.  Such  needs  depend  chiefly  upon  two 
thmgs:  congestion,  favoring  much  association  between 
persons  and  families  in  close  proximity  to  one  another; 
and  intercommunication,  enabling  ready  and  rapid  inter- 
change of  persons  and  commodities  between  communities 
at  a  distance  from  one  another.  Consider,  for  example, 
a  rural  district  where  the  families  have  separate  and  inde- 
pendent water-supplies,  raise  their  own  foods,  live  on  iso- 
lated farms,  and  have  little  communication,  either  by  per- 
son or  otherwise  with  one  another  or  with  persons  outside 
of  their  limited  environment.  Under  such  conditions  there 
are  practically  no  problems  of  public  hygiene.  The  hy- 
gienic problems  are  of  a  personal  character,  or  at  least 
limited  to  the  family.  But  once  such  a  community  begins 
to  concentrate  itself  in  even  the  smallest  hamlets,  sanitary 
problems  of  a  public  nature  begin  to  appear;  and  when 
intercommunication  with  the  outer  world  begins,  then  the 
sanitary  problems  (as  we  have  seen  in  a  previous  chapter) 
take  on  a  state-wide  character. 

While  sanitary  needs  remain  always  fundamentally  the 
same,  the  forms  in  which  they  appear  are  ever  changing 
and  ever  new.  In  the  progress  of  civilization  from  the 
simple  to  the  complex,  man  produces  for  himself  not  only 
new  conveniences  and  comforts  but  also,  simultaneously, 
new  inconveniences  and  discomforts.  In  making  life  in 
some  respects  more  secure,  he  makes  it  in  other  respects 
more  dangerous.  A  whole  step  forward  may  involve  a 
half-step  back.  New  problems  grow.  Hydra-like,  even  in 
the  moment  the  old  are  cut  away.  In  the  bargain  which 
man  drives  with  his  natural  enemies  he  must  take  certain 


82  A  MANUAL  FOR   HEALTH  OFFICERS 

new  disadvantages  as  part  of  the  exchange.     Sanitation 
can  never  be  a  finished  art. 

Anomalous  Position  of  Modern  Sanitary  Authorities.  — 
Sanitary  authorities  today,  in  their  powers  and  methods, 
are  subject  to  influences  from  two  different  quarters: 
(i)  tradition,  and  (2)  modern  sanitary  science.  There  are 
certain  assumed  duties  which  we  may  call  the  old  public 
health,  venerated  by  many  ofificials  as  the  foundation  of 
their  ofifice  and  demanded,  frequently,  by  public  opinion. 
Side  by  side  with  these  and  at  some  variance  with  them 
are  the  activities  which  modern  discoveries  indicate  as 
the  main  line  of  advance  —  the  new  public  health.  The 
present  in  the  public  health  field  is,  therefore,  a  stage 
of  transition,  of  re-adjustment,  of  expansion.  Hence,  the 
inconsistencies  in  public  health  work,  the  great  differences 
in  balance  and  emphasis  between  one  board  of  health 
and  another,  and  the  absence  of  a  consensus  of  opinion 
as  to  what  constitutes  a  rational  program.  One  board 
lays  the  emphasis  on  plumbing  and  nuisance  inspections 
while  comparatively  neglecting  food  supplies;  another 
expends  its  chief  energy  on  milk  supervision,  or  stringent 
quarantine,  or  some  other  particular  point.  Measures 
zealously  practised  in  one  quarter  are  held  in  slight  esteem 
in  others.  It  is  the  object  of  this  volume  to  examine  into 
such  discrepancies  and,  so  far  as  possible,  to  strike  a  correct 
balance  among  them.  It  is  the  problem  of  the  health 
officer  to  weigh  and  sift,  to  save  what  is  valuable  in  tra- 
dition and  experience  while  casting  out  the  valueless  residue, 
and  at  the  same  time  to  utilize  those  of  the  new  principles 
which  have  been  proved  beyond  doubt. 

THE  OLD  PUBLIC  HEALTH 

We  need  not  go  deeply  into  traditional  public  health 
principles.  They  are  familiar  to  all  who  are  concerned 
with  routine  health  department  work  and  even  to  the 
general  public.     Epidemic  disease  was  suppressed  after  it 


THE   NEW    PUBLIC    HEAL'f'II  83 

had  appeared,  rather  than  prevented  in  the  true  sense. 
The  function  of  nuisance  abatement  loomed  large,  for  the 
pythogenic,  or  filtli  origin,  theory  of  disease  taught  what 
we  now  know  to  be  untrue,  that  disease  may  originate 
in  all  kinds  of  filth.  In  other  directions,  such  as  in  the 
supervision  of  food  supplies,  little  was  attempted. 

Surviving  Fallacies.  —  The  chief  consideration  in  con- 
nection with  the  old  public  health  is  that  we  must  recognize 
the  survival  of  the  old  theories  in  the  popular  mind  and 
even  in  the  minds  of  health  officers  themselves.  Tradition 
gives  way  but  slowly,  and  the  continued  adverse  influence 
of  the  errors  of  the  past  is  still  strongly  felt  today.  Hence 
the  need  for  the  re-education  both  of  health  officers  and 
public.  The  surviving  fallacies  are  all  the  more  difficult 
to  dislodge  in  that  in  many  cases  they  contain  the  element 
of  a  half-truth. 

I .    Sanitary  Significance  of  Dirt 

The  question  of  the  sanitary  significance  of  dirt  has 
probably  been  the  occasion  of  more  loose  thinking  than 
any  other  topic  in  hygiene.  Instinct,  of  course,  teaches  an 
abhorrence  of  decaying  organic  matter,  and  history  gives 
evidence  of  the  care  exercised  in  the  disposal  of  putresci- 
ble  matter.  Then,  in  the  middle  of  the  nineteenth  century, 
was  announced  Murchison's  "  pythogenic  "  theory  of 
disease,  which  held  filth  to  be  dangerous,  not  merely  as 
a  predisposing  condition  or  as  the  possible  vehicle  of 
disease,  but  as  the  very  source  of  disease.  The  materies 
morbi,  or  causative  agent  of  disease,  was  thought  to  arise 
de  novo  out  of  filth.  Today  we  know  that  this  theory  is 
false,  but  even  today  it  still  continues  to  exercise  an 
influence.  Many  persons  still  unfortunately  believe  that 
diphtheria  or  typhoid  fever  or  some  other  disease  may 
arise  from  decaying  garbage  or  may  be  caused  by  the 
much -dreaded  sewer  gas. 

Let  us  separate  the  truth  from  the  error  in  the  vague, 


84  A  MANUAL   FOR  HEALTH  OFFICERS 

general  condemnation  of  filth,  and  discriminate  between 
what  is  actually  dangerous  and  what  is  merely  unpleasant 
or  mildly  detrimental.  Science  now  shows  that  there  are 
various  kinds  of  filth,  some  of  which  are  deadly  —  such  as 
the  undisinfected  excreta  of  typhoid  fever  and  other  intes- 
tinal diseases  —  and  some  of  which  are  practically  harmless, 
a  fact  recognized  in  the  popular  phrase  "  good  honest 
dirt,"  and  between  the  two  extremes  there  are  various 
degrees. 

Certain  things  are  specifically  dangerous:  above  all  the 
disease-spreading  privy  vault;  then,  in  a  lesser  degree,  the 
neglected  manure-pile  breeding  the  disease-bearing  fly, 
stagnant  water  breeding  malarial  or  yellow-fever  mos- 
quitoes, the  unkempt  dwelling  harboring  rats  and  other 
vermin,  potential  carriers  of  specific  disease.  Then  again, 
more  important,  certain  habits  are  dangerous,  and  personal 
uncleanliness  in  a  broad  sense  stands  convicted  by  scien- 
tific evidence  as  being  the  greatest  single  factor  in  the  spread 
of  many  of  the  common  communicable  diseases. 

We  may  go  even  further  and  say  that  dirt  is  at  least 
suspicious  if  not  dangerous,  and  largely  for  the  reason 
that  the  dangerous  kinds  of  dirtiness  and  the  innocuous 
kinds  are  likely  to  be  all  mixed  up  together.  Dirty  sur- 
roundings and  dirty  habits  usually  go  together.  A  city 
with  dirty  streets  is  presumably  one  controlled  by  slovenly 
or  indifferent  people,  and  those  are  the  class  which  sanita- 
rians have  learned  to  fear.  Again,  it  is  doubtless  true  that 
dirt  in  itself  exerts  a  depressing  influence  on  the  human 
organism,  particularly  that  of  the  infant. 

Such  facts  clearly  show  that  filth  is,  generally  speaking, 
inimical  to  health  and  a  subject  for  health  administration. 
The  present  difficulty,  however,  is  that  there  is  in  practice 
little  or  no  discrimination  among  the  difl^erent  kinds  of 
filth.  In  other  words,  the  health  officer  —  whose  resources 
are  limited  —  must  recognize  what  forms  of  uncleanliness 
are  most  objectionable  and  attack  those  first.     Thus,  he 


THE   NICW    PUBLIC   HEALTH  85 

will  find  that  while  a  campaign  for  street-cleaning  will 
produce  little  in  the  way  of  vital  results,  a  campaign  for 
sewers  and  the  abolition  of  privy- vaults  will  result  in  great 
and  immediate  benefit  to  public  health.  Never  should 
he  be  led  to  expend  valuable  energy,  needed  for  more 
important  matters,  in  pursuing  merely  superficial  condi- 
tions, such  as  dirty  alleys,  faulty  garbage  collection,  and 
the  like.  These  may  be  real  complaints  and  should  be 
dealt  with  as  effectively  as  may  be,  but  they  are,  it  must 
always  be  remembered,  distinctly  subordinate  in  the  public 
health  campaign.  Let  him  rather  wage  war  on  the  known 
modes  of  the  spread  of  disease:  dirty  hands  and  food 
supplies,  the  unclean  typhoid  carrier,  the  insanitary  privy- 
vault,  and  the  like. 

The  most  damaging  effect  of  false  ideas  as  to  dirt  is  that 
attention  is  distracted  from  more  important  things.  Thus, 
we  now  know  that  the  most  dangerous  kind  of  uncleanli- 
ness  is  personal  uncleanliness,  and  persons  who  forget  this 
and  clamor  instead  about  inadequacies  in  garbage  collection 
and  plumbing  inspection  are  ignoring,  and  leading  others 
to  neglect,  the  real  paths  of  infection. 

2.    Sewer  Gas  and  Foul  Odors 

A  special  misconception  of  the  class  just  referred  to 
relates  to  the  supposed  dangers  from  sewer  gas  and  foul 
odors.  The  emanations  from  sewage  and  other  decom- 
posing organic  matter  have,  erroneously,  been  held  directly 
responsible  for  typhoid  fever,  diphtheria,  malaria,  and 
what-not;  and  the  sewer-gas  bugaboo  is  still  apparently 
entertained  by  most  people  today.  The  strictness  of 
plumbing  regulations  is  a  testimony  to  the  importance 
ascribed  to  the  exclusion  of  even  minute  quantities  of  sewer 
gas  from  dwellings. 

The  theory  of  sewer  gas  as  a  source  of  disease  has  been 
exploded  by  researches  which  prove  that  it  is  practically 
free  from  elements  especially  detrimental  to  health  and 


86  A  MANUAL   FOR   HEALTH  OFFICERS 

that  the  danger  of  air  infection,  even  from  foaming  and 
splashing  sewage,  is  practically  negligible.^  Nevertheless, 
the  popular  notion  of  the  dangers  from  sewer  gas  still 
vigorously  persists,  being,  as  Rosenau  says,  "  the  residual 
legatee  of  Murchison's  pythogenic  theory." 

Of  course,  sewer  gas  is  detrimental  to  comfort  and  may 
exert  a  depressing  influence  on  the  human  organism.  Foul 
odors  presumed  to  arise  from  defective  plumbing  and  the 
like  should  not  be  permitted  to  pass  without  inspection. 
They  may  indicate  conditions  dangerous  to  health,  such, 
for  example,  as  improper  disposal  of  excreta,  or  broken 
drains  giving  rise  to  infection  through  flies,  vermin,  or 
food  or  water  supplies.  Also,  the  odors  in  question  may 
really  be  due  to  escapage  of  illuminating  gas,  which,  even 
in  small  quantities  in  the  air  of  a  dwelling-house,  may  be 
highly  detrimental  to  health. 

But  we  no  longer  trace  any  special  connection  between 
sewer  gas  and  disease,  and  it  is  to  be  hoped  that  popular 
alarms  on  the  subject  will  soon  cease. 

3.    Stagnant  Water  and  Miasms 

A  connection  between  stagnant  water  ancl  fevers  is 
traditional.  Related  to  it  is  mistrust  of  the  upturned 
soil  and  of  the  night  air  in  marshy  regions.  In  general, 
residence  in  low,  damp,  or  marshy  regions  or  in  the  neigh- 
borhood of  swamps  has  been  thought  unhealthful  because 
of  the  supposed  poisonous  "  miasms "  arising  therefrom. 
And,  certainly,  fevers  have  frequently  attacked  persons 
under  such  conditions. 

Sanitary  science  now  explains  the  underlying  phenomena 
of  such  experience.  The  fevers  in  question  are  usually 
either  malarial  or  typhoid  fever.  The  first  is  transmitted 
through  the  bite  of  the  anopheles  mosquito  (and  only 
thus),  and  such  mosquitoes  breed  in  stagnant  water.     The 

'  See  Rosenau,  "Preventive  Medicine  ancl  Hygiene,"  1913.  pp. 
638-640. 


THK   NKW    I'lJHIJC    llliAI/llf  87 

same  may  be  said  of  yellow  fever,  transmitted  by  another 
species  of  mos([uito  in  the  swampy  regions  of  the  south 
and  the  tropics.  The  upturning  of  soil  incident  to  certain 
kinds  of  construction  work  means  hollows  for  the  accumu- 
lation and  stagnation  of  water,  while  the  presence  among 
laborers  (e.g.,  those  from  malarial  districts  of  Italy  and 
elsewhere)  of  malarial  individuals  who  act  as  a  source  of 
infection  of  the  mosquitoes  is  not  unlikely.  The  suspicion 
of  night  air  is  explained  by  the  fact  that  the  anopheles 
(malarial)  mosquito  flies  only  by  night.  Witness  the  classic 
experiments  of  Sambon,  Low  and  Terzi,  who  avoided  con- 
tracting malaria  in  the  malarial  Roman  Campagna  by 
the  simple  precaution  of  keeping  within  their  well-screened 
hut  from  before  sunset  until  after  sunrise.  Thus  science 
explains  a  popular  suspicion  by  showing  exactly  what  the 
danger  to  health  is. 

In  a  somewhat  similar  manner  an  indirect  connection 
may  be  traced  between  the  upturning  of  soil  and  the  occur- 
rence of  typhoid  fever.  Consider  that  excavation  work 
means  the  presence  of  laborers,  some  of  whom  may  be 
mildly  infected  typhoid  "  carriers."  Consider  further  that 
the  sanitary  arrangements  may  be  very  imperfect,  and  the 
infection  of  the  neighborhood  through  flies,  water,  etc.,  may 
thus  readily  take  place.  The  lesson,  of  course,  is  not  the 
avoidance  of  excavations,  as  once  was  thought,  but  proper 
sanitation  in  connection  with  them. 

4.    Imaginary  Purification  of  Running  Water 

As  for  water-supplies,  stagnant  water  is  on  the  whole 
less  likely  to  convey  infection  than  flowing.  The  saying 
"  running  water  purifies  itself  "  has  been  a  disastrous  one 
in  the  history  of  sanitation.  Some  popular  tradition  even 
asserts  that  water  is  purified  after  running  seven  miles. 
We  now  know  that  while  indeed,  through  the  aeration  of 
splashing,  chemical  purification  may  be  favored  in  a 
running  stream,  and  the  water  made  agreeable  to  sight 


88  A  MANUAL   FOR   HEALTH  OFFICERS 

and  smell,  the  same  rule  does  not  apply  to  bacterial  purifi- 
cation. A  sparkling  water  may  still  contain  the  germs  of 
typhoid  fever  or  other  intestinal  disease;  mere  appearances 
are  no  criterion.  The  modern  science  of  water  bacteri- 
ology shows  that  purification  from  pathogenic  germs  is 
favored  in  standijig  rather  than  in  running  water.  The 
principal  purifying  factors  are  sedimentation  (or  settling 
out  of  suspended  matters)  and  time.  Hence  the  value 
of  storage  of  water  supplies.  In  rapidly  running  waters 
these  factors  have  no  place,  hence  the  greater  danger  of 
conveyance  of  infection.     (See  Part  II,  Chapter  IV.) 

Further  examples  of  the  popular  misconceptions  so 
frequently  met  with,  which  the  health  officer  has  to  combat, 
might  be  given,  but  enough  has  been  said  to  clear  the 
ground  for  a  consideration  of  the  duties  of  sanitary  author- 
ities as  pointed  out  by  modern  sanitary  science. 

THE  NEW  PUBLIC  HEALTH 

The  sanitary  science  of  today  is  characterized  by  definite 
qualitative  and  quantitative  knowledge.  Of  this  fact  the 
great  example  is  to  be  seen  in  the  germ  theory  of  disease 
and  its  far-reaching  developments  in  sanitary  and  patho- 
logical bacteriology.  Instead  of  "  miasms,"  "  influences," 
"  poisons,"  materies  morbi,  and  other  vaguely  surmised 
causes  of  disease,  there  is  now  definite  knowledge  of  specific 
causative  organisms :  the  bacilli  of  tuberculosis,  diphtheria, 
typhoid  fever,  and  the  rest.  The  list  of  communicable 
diseases  subject  to  control  has  been  much  lengthened. 
Distinctions  have  been  worked  out;  we  know  that  some 
diseases  may  creep  like  fire  in  the  underbrush,  while  others 
spread  like  wildfire. 

Tuberculosis,  once  supposed  hereditary  and  non-pre- 
ventable, is  now  transferred  to  the  list  of  preventables. 
To  that  list  the  whole  class  of  insect-borne  diseases  is 
added.  Nuisances  are  scrutinized  to  ascertain  whether 
they  really  favor  or  indicate  the  transmission  of  disease 


THE   NEW   PUBLIC   HEALTH  89 

or  whether  they  are  merely  objectionable  on  grounds  of 
aesthetics,  decency,  or  comfort.  In  the  hygiene  of  air- 
supplies,  instead  of  the  theorizings  which  have  left  ventila- 
tion one  of  the  least  developed  of  the  sanitary  arts,  there 
is  definite  and  increasing  knowledge  as  to  the  physiological 
effects  of  heat,  humidity,  dust  and  gases,  and  ventilating 
engineering  is  now  a  distinct  and  progressing  art.  In 
regard  to  water-supplies,  bacteriology  shows  that  the  pres- 
ence of  the  specific  germs  of  typhoid  fever  and  other 
water-borne  diseases  must  be  guarded  against  and  that 
mere  absence  of  offensive  odor  and  taste  does  not  assure 
this;  while  bacteriology  and  chemistry  join  in  furnishing 
the  means  of  detecting  the  presence  of  the  germs  and  of 
the  sewage  matters  associated  with  them.  As  to  food- 
supplies,  the  dangers  of  transmission  of  germ  disease  by 
articles  of  food  (especially  milk)  are  clearly  recognized, 
while  on  the  other  hand  deleterious  contamination,  fer- 
mentations, and  decompositions  are  much  better  under- 
stood than  formerly.  In  short,  there  has  been  built  an 
imposing  and  still  growing  structure  of  sanitary  science, 
of  which  epidemiology,  sanitary  bacteriology,  sanitary 
chemistry,  and  the  allied  sciences  are  the  component  parts. 
In  the  new  methods,  both  technical  and  administra- 
tive, the  quantitative  element  is  prominent.  The  question, 
"  Is  this  or  that  detrimental  to  the  public  health?  "  is 
followed  by  the  inquiry,  "  How  detrimental?  "  Many 
things  affect  the  public  health  and  practical  considerations 
forbid  equal  attention  to  all  of  them.  In  any  particular 
instance  the  problem  is  whether  administrative  measures 
are  advisable,  and,  if  so,  what  they  shall  be  and  how  far 
they  shall  go.  Does  terminal  disinfection  always  pay? 
Which,  judged  from  sanitary  and  economic  standpoints, 
is  the  better  course:  pasteurization  of  milk  or  the  elimina- 
tion of  tuberculous  cows?  Such  quantitative  questions 
as  these  are  common.  Expenditure  of  money  must  be 
adjusted  to  probable  results,  and  sanitary  research  and 


go  A  MANUAL   FOR   HEALTH  OFFICERS 

murticipal  budgets  are  coming  into  closer  relation.  The 
methods  of  the  actuary  are  applied  to  public  health  work, 
and  results,  so  far  as  they  are  economic,  are  estimated 
in  terms  of  dollars  and  cents.  The  economic  problems 
arising  out  of  sanitary  restrictions  are  receiving  attention. 
The  new  public  health  applies  principles,  rather  than 
formulas  or  customs.  Problems  are  decided,  not  by 
dictum  or  on  a  priori  grounds,  but  by  actual  test,  in  the 
laboratory,  in  the  field,  or  at  the  statistical  desk.  Health 
departments  are  being  overhauled  and  time-honored 
routines  put  to  the  test. 

Scope  of  the  New  Public  Health 

The  field  of  the  new  public  health  may  be  summarized 
as  follows: 

I.  General  Administration. 

II.   Registration  {reports  of  communicable  disease,  vital 
statistics,  etc.). 

III.  General    Sanitation     {housing,    factory    sanitatiojt, 

nuisances,  etc.). 

IV.  Prevention  and  Control  of  Communicable  Disease. 
V.   Child  Hygiene. 

VI.  Supervision  of  Food  and  Water  Siipplies. 

VII.  Other  Functions  {maintenance  of  hospitals,  research, 
etc.). 

In  comparison  with  the  ideas  of  the  old  public  health  we 
see  many  changes  and  developments  in  the  above. 

General  administration  and  registration  work,  for  ex- 
ample, have  become  so  important  as  to  merit  separate 
classification. 

The  old  function  of  nuisance  abatement  is  now  reck- 
oned as  only  a  subdivision  of  the  general  sanitary  control 
of  the  new  environment,  in  which  the  housing  and  factory 
problems  now  loom  large.  The  old  function  of  suppressing 
epidemics  after  their  appearance  has  been  enlarged  until 
it  now  means  the  constant  control,  by  scientific  prevention, 


THp;  Nicw  I'ui'.i.ic   iii;,\i;i'ii  91 

of  communicable  disease  at  all  Limes.  Sanitary  aiillioiilies 
are  even  going  further  and  in  infant  hygiene  work  are 
attacking  disease  which  is  preventable  though  not  commu- 
nicable by  methods  which  press  into  the  realm  of  personal 
hygiene. 

The  supervision  of  food  supplies  has  been  much  extended, 
as  may  be  seen  from  the  present-day  complex  pure  food 
laws.  The  regulation  of  milk-supplies  has  received  an 
especially  large  share  of  attention.  To  this  head  has  also 
been  added  the  scientific  control  of  water-supplies. 

The  list  does  not  include  public  works  of  the  nature  of 
sanitary  engineering  —  e.g.,  refuse  collection  and  disposal, 
street-cleaning,  sewerage  (including  plumbing  inspection), 
and  the  like  —  for  the  reason  that  these  should  be  assigned 
to  the  engineering  departments  of  municipal  administra- 
tion. While  these,  like  parks  and  water-supplies,  indirectly 
afifect  public  health,  they  are  not  primarily  matters  of  health 
administration,  and  a  natural  division  of  activities  requires 
that  they  be  assigned  to  special  city  departments. 

The  vantage  point  in  the  shift  from  old  to  new  is  indi- 
cated by  Dr.  H.  W.  HilF  (whose  phrasing  suggested  the 
title  of  the  present  chapter)  in  the  statement  that  "  the 
old  public  health  was  concerned  with  the  environment; 
the  new  is  concerned  with  the  individual.  The  old  sought 
the  sources  of  infection  in  the  surroundings  of  man;  the 
new  finds  them  in  man  himself."  There  is  much  truth  in 
this.  Human  conduct  is  the  great  factor  in  public  hygiene, 
and  also  the  most  difficult  to  control.  Persons  and  their 
actions  (especially  their  habits)  are  more  important  than 
things  and  their  properties.  Even  the  problem  of  environ- 
ment is,  of  course,  one  of  the  modifications  by  man  of  the 
conditions  surrounding  his  life,  and  not  of  mere  passive 
protection  against  them. 

1  Hill,  "The  New  Public  Health,"  Press  of  the  Journal-Lancet,  Min- 
neapolis, Minn.,  1913  (50  cents);  also  book  of  same  title  (Macmillan, 
1914). 


9^  A   MANUAL    FOR   IIIIALTH  OFFICERS 

Sanitary  Education  and  Publicity.  —  A  notable  charac- 
teristic of  the  new  scheme  is  the  education  of  the  people 
in  some  of  the  elements  of  personal  and  public  hygiene. 
Sanitary  education  implies  not  only  sound  instruction  of 
the  growing  generation,  but  also  popular  enlightenment 
through  systematized  publicity  work.  The  latter  will  be 
taken  up  later  in  a  separate  chapter. 

Some  Uncontrollable  Factors.  —  The  program  which  has 
been  sketched  by  no  means  covers  the  whole  range  of 
factors  affecting  the  public  health,  but  only  those  suscep- 
tible of  public  control.  The  uncontrollable,  or  only  partly 
controllable,  factors  should  not  be  lost  sight  of  in  any 
estimate  of  administration  and  its  results. 

The  character  of  the  population,  for  example,  may  pre- 
sent many  such.  Age  and  race  distribution  may  favor  or 
may  work  against  measures  of  sanitary  control.  Thus, 
the  large  negro  element  in  the  South  tends  to  produce  an 
increased  mortality  which  is  combatted  with  difficulty 
by  the  sanitary  authorities.  Then  there  are  climatic 
conditions:  the  long  warm  seasons  of  the  South  favor  the 
life  of  pathogenic  organisms  in  the  environment  and  tend 
to  increase  the  incidence  of  insect-borne  diseases;  while 
more  severe  and  changeable  climates  favor  affections  of 
the  respiratory  system.  Seasonal  variations  have  their 
effects,  as  has  been  noted  in  the  tendency  of  hot  summers 
to  increase  infant  mortality.  Standards  of  living,  which 
are  notoriously  subject  to  fluctuation,  undoubtedly  affect 
the  public  health.^  Some  of  these  influences  affecting  the 
general  death-rate  will  be  discussed  more  fully  under 
Vital  Statistics. 

Proportion  in  Work  of  Sanitary  Authorities.  —  The 
prime  duty  of  sanitary  authorities  is  to  strive  toward 
higher   ideals   of   administration.     In   order   to   approach 

^  Although  this  subject  is  of  considerable  sanitary  and  sociological 
interest,  it  is  little  understood.  There  is  reason  to  believe  that  the 
phenomena  are  not  altogether  what  would  be  anticipated;   for  example, 


THE   NKW    PUUIJC    IIKAL'I'II  93 

those  ideals  it  is  necessary  to  do  certain  things  very  well 
indeed,  which  means  that  the  field  for  action  must  be 
carefully  defined  in  order  that  energy  may  not  be  spent 
in  ways  of  little  profit.  The  usual  health  appropriation 
allows  no  room  for  expenditures  which  do  not  directly 
and  demonstrably  affect  the  public  health  and  the  health 
officer  is  to  be  congratulated  who,  without  waste  of  money 
or  effort,  recognizes  and  accomplishes  the  essential  for  his 
community. "^  The  law  of  diminishing  returns  must  be 
taken  into  account.  Outside  of  the  things  that  may 
easily  be  distinguished  as  obvious  duties  there  is  a  choice 
which  requires  discretion.  The  health  officer  feels  himself 
drawn  to  go  into  publicity  work,  to  co-operate  with  phi- 
lanthropies, perhaps  to  take  counsel  with  civic  reformers. 
These  things  may  be  good  in  a  degree,  but  must  be  sub- 
ordinated to  a  well-balanced  administrative  program. 

Obstacles  to  Progress.  —  Ignorance  of  sanitary  needs 
and  indifference  to  them  are  the  chief  enemies  of  sanitary 
progress.  One  role  of  the  health  officer  is  to  point  out 
both  needs  and  remedies  and  to  break  the  vicious  circle 
of  low  standards,  insufficient  funds,  and  poor  sanitation 
which  not  infrequently  prevails.  The  first  step  is  the 
preparation  of  a  statement  of  needs,  based  so  far  as  possible 
on  reliable  vital  statistics,  with  a  detailed  scheme  of  pro- 
posed work  with  its  cost.  Judicious  publicity  on  the 
situation  and   tact  in  obtaining  the  cooperation    of    the 

"hard  times,"  instead  of  increasing  death  rates  through  privation, 
lowered  nutrition,  etc.,  appear,  under  some  circumstances  at  least, 
to  decrease  them  through  enforced  moderation  in  labor,  food,  and 
drink,  enforced  idling  (in  the  open  air),  and  reduction  to  simple,  inex- 
pensive, and  healthful  pleasures.  Industrial  depression  also  tends  to 
decrease  birth-rates,  which  would  mean  a  lower  infant  mortality. 
Some  remarks  on  the  question  are  included  in  a  paper  by  W.  T.  Sedg- 
wick and  the  present  writer:  "On  the  Mills-Reincke  Phenomenon, 
etc.,"  Jour.  Inf.  Diseases,  1910,  vol.  VII,  no.  4,  p.  489. 

^  See  Chapin,  "How  Shall  We  Spend  the  Health  Appropriation?" 
Ant.  Jour.  Pub.  Health,  1913,  vol.  Ill,  no.  3,  p.  202. 


04  A   MANUAL  FOR   HEALTH  OFFICERS 

council  or  other  governing  body  whicii  fixes  appropriations, 
are  important  considerations.  When  the  results  that  will 
follow  the  accomplishment  of  a  thorough  public  health 
program  are  pointed  out,  the  cost  should  cease  to  be  an 
objection. 

Local  pride  must  be  tactfully  dealt  with.  Almost 
every  community  is  under  the  impression,  fostered  perhaps 
by  the  utterances  of  prominent  but  uninformed  citizens, 
that  it  is  one  of  the  healthiest  spots  in  the  United  States. 
This  impression  is  strengthened  in  numerous  ways  and  is 
usually  left  untouched,  if  it  is  not  supported,  by  the  public 
press.  It  is  an  impression  which  people  unconsciously 
wish  to  have  strengthened,  just  as  the  individual  likes 
to  minimize  any  ailment  he  may  have  and  avoids  consult- 
ing the  doctor,  who,  he  knows,  may  prescribe  some  radical 
change  in  regimen.  The  average  community  will  put 
up  with  a  great  many  surface  indications  of  radically  bad 
conditions  before  it  will  turn  its  attention  to  the  conditions 
themselves  and  their  remedies.  For  one  reason,  such  in- 
dications are  usually  scattered.  One  citizen  or  group  of 
citizens  has  but  a  very  limited  view,  and  so  long  as  there 
is  no  general  "  survey,"  conditions  in  the  mass  are  un- 
known to  the  citizens  as  a  mass.  If  a  citizen  or  society 
with  the  reform  spirit  rises  and  proclaims  the  salient  re- 
sults of  investigation,  he  is  likely  to  be  treated  at  first  to 
the  same  old  indifference.  If,  however,  he  perseveres  in 
urging  a  few  striking  points  in  such  a  way  as  to  move  his 
public  without  antagonizing  it,  he  will  eventually  get  a 
hearing.  The  problem  then  is  to  get  a  thorough  survey 
and  study  of  the  facts,  in  which  it  may  be  necessary  to 
obtain  the  services  of  a  qualified  sanitary  expert  —  not  a 
mere  passing  "  investigation  "  which  leaves  fundamental 
conditions  untouched;  and,  finally,  to  get  permanent 
remedial  action.  In  this  last  object  the  health  officer  may 
have  to  consider  what  motives  are  to  be  urged  for  more 
and  better  public  health  work. 


THE   NEW    PUBLIC   HEALTH  95 

The  Motives  for  Public  Health  Work.  —  Indifference 
may  go  on  until  some  appalling  revelation  or  even  a  severe 
attack  of  epidemic  disease  compels  attention.  There  are 
instances  in  which  pubHc  health  reform  was  i)recipitated 
by  an  epidemic.  Thus  the  town  of  Montclair,  New  Jersey, 
experienced  in  1894  a  severe  epidemic  of  milk-borne  ty- 
phoid fever,  as  a  consequence  of  which  the  town  immedi- 
ately instituted  thorough  health  work  under  a  full-time, 
trained  health  officer  and  has  had  a  health  department 
of  a  high  order  ever  since.  Before  going  through  such  an 
experience  it  is  but  prudence  to  take  stock  of  the  situation 
in  time. 

What  motives  may  be  appealed  to  for  support  of  public 
health  work?  It  has  been  proposed  in  some  quarters  to 
estimate  the  results  of  such  work  in  dollars  and  cents  and 
to  use  such  an  estimate  as  the  basis  of  appeal.  Given 
certain  pecuniary  values  of  lives,  a  rough  estimate  may  be 
made  of  the  economic  saving  in  mortality  and  morbidity 
avoided.  The  money  argument  has  been  advanced  by 
Irving  Fisher  and  other  economists  and  sociologists  who 
aim  to  replace  vague  sentimental  appeals  by  something 
more  tangible.  On  this  principle  Whipple  ^  has  worked 
out  in  money  terms  the  saving  in  sickness  and  deaths 
resultant  from  the  substitution  of  pure  for  polluted  public 
water-supplies. 

This  method  of  appeal,  however,  has  not,  it  seems  to 
the  writer,  a  wide  range  of  usefulness.  The  fact  is  that 
as  Chapin  -  says,  "  there  is  much  in  the  world  which  cannot 
be  measured  in  terms  of  money,  though  to  so  measure  it 
is  doubtless  the  tendency  of  the  age."  The  money  valua- 
tion is  highly  inexact  and  does  not  cover  the  whole  question 
of  benefits  from  health  work.  The  lives  of  laborers  may 
have  a  low  economic  value,  yet  are  as  much  entitled  to 

^  Whipple,  "The  Value  of  Pure  Water." 

2  Chapin,  "The  Value  of  Human  Life,"  Am.  Jour.  Public  Health, 
1913,  vol.  3,  no.  2,  p.  loi. 


96  A  MANUAL  FOR   HEALTH  OFFICERS 

the  protection  of  the  law  as  those  of  individuals  of  greater 
economic  value.  Of  course,  it  is  not  to  be  denied  that  in 
dealing  with  finance  committees  certain  money  calcula- 
tions of  proposed  benefits  may  have  some  value  and  may 
be  used  for  what  they  are  worth. 

On  the  whole,  it  is  best  to  base  arguments  for  health 
work  directly  upon  high  ideals  of  administration  and  make 
quantitative  statements  in  terms  of  lives  saved  (or  to  be 
saved)  and  sicknesses  prevented,  leaving  to  the  imagina- 
tion the  immensurable  total  saving  in  suffering,  sorrow, 
economic  loss,  and  the  rest,  which  is  implied.  Such  is 
the  true  use  of  vital  statistics.  Costs  may  be  expressed 
in  dollars  and  cents,  but  the  natural  and  direct  expression 
of  results  is  in  the  saving  of  vitality. 

The  Costs  of  Public  Health  Work.  —  Owing  to  local 
differences  it  is  impossible  to  set  any  hard  and  fast  figure 
as  a  standard  for  health  expenditures.  Various  estimates 
for  the  minimum  wage  which  would  be  required  by  most 
health  departments  have,  however,  been  made,  while 
figures  as  to  actual  expenditures  have  been  collected  by 
Schneider.^  The  Committee  on  Activities  of  Municipal 
Health  Departments,  of  the  American  Public  Health  Asso- 
ciation, set  the  minimum  per  capita  appropriation  required 
at  50  cents.-  One  authority  (Park)  asks  for  a  minimum 
ranging  from  50  cents  to  $1  per  inhabitant,  according  to 
the  size  of  the  city.  The  investigation  by  Schneider  (in 
1913)  showed  that  in  119  American  cities,  containing  in 
1910  a  population  of  17,525,000,  the  yearly  expenditure 
for  prevention  of  disease  was  but  38.4  cents  a  head,  the 

^  Schneider,  "Activities  of  Municipal  Health  Departments,"  De- 
partment of  Surveys  and  Exhibits  of  the  Russell  Sage  Foundation, 
130  East  22nd  St.,  New  York  City. 

^  Such  figures  should,  and  it  is  believed  that  those  here  quoted  do, 
refer  only  to  expenditures  which  are  for  prevention  of  disease  through 
activities  which  are  distinctly  those  of  health  departments,  excluding 
expenditures  for  sewers,  refuse  disposal,  and  other  activities  which 
properly  pertain  to  other  departments  of  the  city  government. 


THE   NKW    I'lJHfJC    HKAI/ni  97 

range  for  individual  cities  being  from  $1.22  down  to  eight- 
tenths  of  I  cent  per  capita.  In  New  York  City,  where 
health  work  has  been  organized  on  an  efficient  basis  longer 
than  in  any  other  American  city,  and  where  health  appro- 
priations are  relatively  generous,  the  per  capita  is  55  cents, 
but  this  is  less  than  three-quarters  of  what  the  health 
commissioner  certifies  as  necessary.  The  health  depart- 
ment of  that  city  has  adopted  the  phrase,  "  Public  health 
is  purchasable,  and  within  natural  limitations  a  commu- 
nity may  determine  its  own  death  rate."  It  is  obvious 
that  health  appropriations  the  country  over  should  be 
increased.  This  and  expert  service  are  the  crying  needs 
of  the  day.  Given  these,  and  effective  organization 
and  activity  will  follow.  Aside  from  such  general  minima 
as  have  been  mentioned  above  (which  are  merely  sugges- 
tive), each  community  must  estimate  its  own  requirements 
in  each  department  of  public  health  activity  and  appro- 
priate accordingly. 

Public  Health  Surveys  and  Programs.  —  In  the  present 
pages  we  deal  with  the  principles  of  public  health  prac- 
tice, leaving  these  to  be  applied  to  local  needs,  which 
may  differ  rather  widely  in  different  places.  It  is  the 
first  duty  of  the  health  officer  —  if  this  has  not  already 
been  done  —  to  make  a  survey  of  the  local  public  health 
situation,  to  study  local  needs,  and  to  formulate  an  effec- 
tive local  program.  In  many  instances  it  would  be  wise 
to  secure  the  services  of  a  public  health  expert  for  the 
special  purpose  of  making  such  a  survey.^ 

REFERENCES 

Sedgwick,  "Principles  of  Sanitarj'  Science  and  the  Public  Health," 
Macmillan,  New  York,  1905. 

Rosenau,  "Preventive  Medicine  and  Hygiene;"  with  chapters  upon 
Sewage  and  Garbage,  by  Whipple;  Vital  Statistics,  by  Wilbur,  etc.; 
Appleton,  New  York,   1913,  is  a  good  general  reference  book  which 

^  See  the  references  to  organizations  specializing  in  such  work, 
p.  63. 


gS  A   MANUAL   FOR  HEALTH  OFFICERS 

will  frequciul}-  be  cited  in  the  following  pages.  Various  other  standard 
works  on  Hygiene  may  also  be  consulted.  Of  special  interest  to  the 
health  officer  of  the  small  town  or  country  district  is  Brewer's  "Rural 
Hygiene,"  Lippincott,  Phila.,  1909;  also  Dresslar,  "Rural  Schoolhouses 
and  Grounds,"  U.  S.  Bur.  Education,  Bull.  12,  1914  (includes  discus- 
sions on  wells  and  privies). 

Allen,  "Civics  and  Health,"  and  Bruere,  "The  New  City  Govern- 
ment," both  dealing  with  health  from  the  standpoint  of  civics  and 
municipal  research. 

Kerr  and  Moll,  "Organization,  Powers  and  Duties  of  Health  Au- 
thorities: An  Analysis  of  the  Laws  and  Regulations  Relating  Thereto 
in  Force  in  the  United  States,"  U.  S.  Public  Health  Service,  Pub. 
Health  Bull.  No.  54,  1912. 

The  publications  of  the  Federal  Government,  particularly  the  "Pub- 
lic Health  Reports"  (a  weekly  statistical  review  of  national  health 
conditions,  containing  also  articles  on  sanitary  methods  and  organi- 
zation, new  municipal  ordinances,  etc.,  which  may  be  obtained  regularly 
by  any  health  officer  on  application  to  the  U.  S.  Public  Health  Service, 
Washington),  and  the  Bulletins  of  the  Hygienic  Laboratory  dealing 
with  subjects  of  sanitary  research  and  organization  (may  be  obtained 
as  above).  The  Department  of  Agriculture  issues  a  monthly  list 
of  new  publications,  which  will  be  sent  regularly  on  request.  For  a 
general  description  of  Federal  publications  see  Price  List  51,  covering 
Health  and  Hygiene,  obtainable  from  the  Supt.  of  Documents,  Gov- 
ernment Printing  Office,  Washington,  D.  C,  to  whom  requests  for  such 
publications  should  be  addressed.  Most  of  the  Federal  publications 
are  sold  at  low  prices  in  order  to  defray  cost  of  publication. 

Frequent  reference  is  made  throughout  this  book  to  the  American 
Journal  of  Public  Health,  published  by  the  American  Public  Health 
Association  at  755  Boylston  Street,  Boston  (subscription  three  dollars 
per  annum),  files  of  which  are  indispensable  to  the  health  officer.  Pre- 
vious to  1912  this  publication  was  called  the  Journal  of  the  American 
Public  Health  Association,  and  still  earlier,  the  American  Journal  of 
Public  Hygiene. 


PART   II 
PUBLIC    HEALTH    ADMINISTRATION 


CHAPTER   I 
COMMUNICABLE   DISEASE 

The  most  important  group  of  duties  falling  to  the  health 
authorities  is  that  under  the  head  of  communicable  disease. 

Terms.  —  It  was  formerly  the  custom  to  attempt  to 
draw  a  precise  distinction  between  the  terms  "contagious" 
and  "infectious,"  but  modern  theory  has  shown  the  fallacy 
of  such  attempts.  It  is  best  to  group  all  the  diseases 
under  present  consideration  under  the  term  "communica- 
ble" (or  "transmissible"),  which  means  simply  that  they 
may  be  communicated  from  one  person  to  another  (or  in 
some  instances  from  an  animal  to  man),  and  then  to  con- 
sider for  each  division  the  mode  of  communication  of  the 
disease.  When  it  is  seen  that  there  are  many  such  modes 
and  many  degrees  of  communicability,  a  much  clearer  and 
more  practical  conception  will  be  obtained  than  through 
attempting  to  classify  in  hard  and  fast  categories.^ 

Classification  of  Diseases.  —  The  following  classification, 
adopted  from  Rosenau's  "Preventive  Medicine  and  Hy- 
giene" and  based  primarily  upon  practical  sanitary  consid- 
erations, is  used  in  the  present  chapter. 

1  So  far  as  the  terms  can  be  defined  with  any  accuracy,  "  infectious  " 
would  seem  to  apply  to  any  disease  caused  by  microbic  invasion  (Latin 
inficere,  to  put  into,  to  taint),  while  the  term  "  contagious  "  would 
mean  "  capable  of  being  spread  by  (direct  or  indirect)  contact."  In 
popular  parlance  a  contagious  disease  is  one  directly  and  readilj'  com- 
municable—  "catching";  while  an  infectious  disease  is  conveyed  in 
some  indirect  manner.  Neither  term,  however,  has  an  accepted  scientific 
significance,  and  the  terminology  suggested  in  the  text  is  much  pref- 
erable. (Cf.  Rosenau,  "  Preventive  Medicine  and  Hygiene,"  1913, 
page  317). 

lOI 


I02  A  MANUAL   FOR  HEALTH  OFFICERS 

/.   Diseases  spread   largely   through  secretions   or   dis- 
charges from  ?iose,  throat  or  mouth. 
II.   Diseases  spread  largely  through  excreta. 

III.  Diseases  spread  by  insects  and  vermin. 

I V.  Diseases  having  specific  or  special  preventive  measures. 
V.  Miscellaneous  diseases. 

CONTROL   OF   COMMUNICABLE  DISEASE 

Reporting.^  —  Physicians,  persons  in  charge  of  schools  of 
any  kind  (including  Sunday  schools),  and  under  certain 
circumstances,  parents  or  householders,  should  be  required, 
under  heavy  penalty,  to  make  a  prompt  report  of  each  case 
(or  suspected  case)  of  communicable  disease  coming  under 
their  observation.  As  a  general  rule  there  is  no  difficulty 
in  obtaining  good  reporting  of  cases  of  the  acute  commu- 
nicable diseases,  though  there  is  sometimes  a  tendency  on 
the  part  of  physicians  to  delay  diagnosis  for  fear  of  being 
in  the  wrong.  Reports  of  mild  cases  are  also  sometimes 
omitted  where  it  is  thought  that  unofficial  home  isolation 
will  meet  the  situation;  this  is,  of  course,  a  very  repre- 
hensible practice,  though  apparently  not  of  frequent 
occurrence. 

It  sometimes  happens  that  a  patient  is  affected  with  two 
or  more  distinct  diseases  at  once  —  e.g.,  scarlet  fever  and 
diphtheria.  Such  cases  are  known  as  "plural  infections." 
In  such  cases  double  records  should  be  made  out  and  the 
rules  for  both  diseases  apply. 

Suspected  Cases.  —  It  should  be  distinctly  understood 
that  the  public  health  should  be  given  the  benefit  of  the 
doubt  in  all  instances:  that  cases  may  be  reported  as 
"suspected,"  that  the  health  department  will  in  such  cases 
furnish  a  diagnostician  (its  own  physician)  to  assume  the 
responsibility  of  dealing  with  the  case  and  settling  the 

^  The  English  term  "notification"  is  perhaps  preferable,  but  the 
above  is  commonly  used  in  this  country. 


COMMUNICABLE   DISEASE  103 

doubt,  and  that  in  exceptional  cases  the  diagnosis  may,  as 
a  result  of  later  developments,  be  recalled.  It  is  prefer- 
able to  isolate  a  suspected  case  for  a  few  days  rather  than 
allow  it  the  opportunity  to  infect  half-a-dozen  others  dur- 
ing that  time.  Such  cases  should  receive  daily  medical 
scrutiny  with  use  of  the  thermometer. 

Reportable  Diseases.  —  The  list  of  diseases  which 
physicians  are  by  law  required  to  report  is  best  fixed  by 
state  law,  but  is  sometimes,  to  some  extent  at  least,  left 
to  the  local  board  of  health  to  determine.  It  should  include 
all  of  the  diseases  mentioned  in  the  present  chapter  and 
any  others  which  may  concern  the  public  health. 

The  reporting  should  be  made  as  easy  and  systematic 
as  possible  for  the  physician.  Postal  card  forms  (except 
for  tuberculosis,  which  the  law  frequently  requires  to  be 
reported  under  seal)  are  most  convenient. 

It  may,  for  epidemiological  purposes,  be  useful  to  require 
in  the  report  the  name  of  the  milk-dealer  serving  the  family. 

The  practice  of  receiving  reports  over  the  telephone  may 
be  adopted  provided  prompt  confirmatory  notice  is  given 
in  writing.  It  must  be  remembered  that  the  law  com- 
monly requires  the  written  report  and  that  the  latter  is  the 
proper  legal  justification  for  the  action  taken  by  the  health 
authorities. 

Defects  in  Reporting.  —  Satisfactory  reporting  of 
cases  may  be  obtained  through  cultivating  the  cooperation 
of  the  local  practitioners,  explaining  through  circular  letters 
and  reports  the  necessity  for  prompt  and  full  reports  as  a 
basis  for  the  work  of  the  health  department.  Occasion- 
ally prosecution  of  a  grave  offender  is  necessary.  If  the 
reporting  is  not  up  to  the  mark  of  practical  perfection  the 
fault  may  be  laid  at  the  door  of  the  health  ofificer  himself, 
for  upon  him  devolves  both  the  power  and  duty  of  enforc- 
ing the  law. 

By  practical  perfection  we  mean  the  prompt  reporting 
of  all  recognized  cases.     But  even  this  does  not  mean  that 


I04  A  MANUAL  FOR   HEALTH  OFFICERS 

actually  all  cases  are  brought  to  the  attention  of  the  health 
department,  for,  as  will  be  explained  later,  there  are  num- 
bers of  "missed,"  or  unrecognized,  cases,  which  never 
reach  the  records. 

Investigation  and  Action.  —  Reported  cases  are  at  once 
made  the  basis  of  investigation  and  action  by  the  health 
officer  or  by  a  trained  inspector.  The  importance  of 
promptitude  in  looking  up  reported  cases  is  very  great; 
immediate  isolation,  for  example,  may  save  several  cases 
or  an  outbreak  later.  Again,  milk  or  other  food  supplies 
may  be  in  need  of  prompt  protection.  The  specific  action 
to  be  taken  for  each  disease  will  be  outlined  later  under  the 
various  heads. 

On  his  first  visit  the  inspector  fills  out  a  blank  form  called 
a  history  of  the  case,  on  which  are  entered  data  concerning 
the  circumstances  of  the  case  and  possible  sources  of  infec- 
tion. He  prescribes  whatever  measures  are  necessary  in 
the  case  and  adds  to  the  history  a  memorandum  of  them. 
This  history  is  then  placed  on  file  at  the  office  for  reference. 
It  not  only  furnishes  information,  statistical  and  otherwise, 
but  also,  with  the  physician's  written  report,  constitutes 
evidence  of  legal  justification  for  the  action  taken. 

Recording.  —  The  recording  system  for  communicable 
disease  must  be  full,  easy  to  manipulate,  and  afford  ready 
means  for  any  statistical  studies  that  may  be  necessary. 
The  system  may  comprise: 

1.  Original  physicians'  reports,  filed  in  order  of  receipt. 

2.  History  cards,  filed  by  name  or  address. 

3.  A  book  record,  giving  main  data  of  the  cases  in  same 
order  as  physicians'  reports,  dates  of  action  taken,  etc.^ 

4.  A  "spot  map,"  showing  locations  of  cases. 

*  Columns  may  be  provided  for  the  following  items:  Name,  Case 
No.,  St.  and  No.,  Age,  Disease,  Date  of  Rpt.,  Physician,  Milkman, 
Date  of  Attack,  Number  of  School  Children,  School  Attended,  Reported 
to  School,  Libraries,  Milk  Station,  etc.,  Outcome  of  Case,  Disinfection 
Measures. 


COMMUNICABLE   DISEASE  105 

5.  Physicians'  reports  of  termination  of  cases,  filed  in 
order  of  receipt. 

Any  good  large-scale  map  of  the  town  (such  as  may  be 
obtained  from  the  town  engineer  or  a  surveyor)  may  be 
used  for  the  basis  of  the  spot  map ;  the  various  diseases  may 
be  indicated  by  tacks  or  pins  having  heads  of  different 
colors  (those  known  as  "routing  tacks"  and  furnished  by 
stationers  are  useful)  and  when  a  case  is  terminated  the 
location  may  be  marked  by  a  colored  spot.  The  map  may 
be  run  for  a  year  and  then  be  replaced  by  a  new  one  to  be 
started  afresh. 

In  addition  to  the  above  other  forms  will  readily  suggest 
themselves.  Inspectors  may,  for  example,  run  a  record 
of  inspections  and  disinfections  performed.  It  may  be 
desired  to  make  special  studies  as  to  milk-supply,  etc.,  but 
in  general  careful  study  of  the  above-mentioned  records 
will  give  the  essential  understanding  of  the  situation. 

Notification  of  Schools,  etc.  —  Cases  of  diseases  of  child- 
hood should  be  reported  promptly  by  the  health  depart- 
ment to  the  school  authorities  by  telephone.  The  names 
of  school-children  in  the  house  should  be  reported;  if 
there  are  no  school-children  the  report  should  nevertheless 
be  made  so  that  the  school  authorities  may  confirm  the 
fact  to  their  own  satisfaction.  Communication  should  be 
made  as  to  whether  the  patient  is  isolated  at  home  or  has 
gone  to  the  isolation  hospital.  Termination  of  isolation 
and  return  from  hospital  should  be  reported  in  the  same 
manner.  The  relation  of  communicable  disease  to  the 
schools  will  be  discussed  later  (page  254). 

The  same  data  should  be  reported  by  telephone  to  in- 
fants' consultation  and  milk  stations  and  public  and  private 
circulating  libraries  (page  263). 

It  may  also  be  desirable  to  report  to  large  milk  companies 
the  names  and  addresses  of  quarantined  families  on  their 
routes. 

If  there  is  a  local  anti-tuberculosis  society,  tuberculosis 


Io6  A  MANUAL  FOR  HEALTH  OFFICERS 

should  be  reported  to  it  by  regular  arrangement.  Care 
should  be  taken,  however,  that  no  legal  provision  is  vio- 
lated in  so  doing.  The  law  usually  provides  that  the  data 
of  tuberculosis  reports  shall  be  kept  confidential,  but  there 
should  be  a  proviso  that  they  may  be  communicated  by  the 
health  authorities  so  far  as  measures  for  the  control  of  the 
disease  require.  Such  a  proviso  would  permit  reports  to 
unofficial  anti-tuberculosis  societies  which  would  make  the 
same  sort  of  use  of  them  that  a  health  department  might. 
Such  reports  should  include  statements  of  new  cases,  new 
reports  of  old  cases,  changes  of  address,  deaths,  disinfec- 
tions and  related  facts.  The  records  of  the  society  may 
from  time  to  time  be  checked  over  against  those  of  the 
health  department  to  see  that  they  agree. 

Reports  made  as  above  should  be  recorded  in  the  com- 
municable disease  record  book. 

The  reports  required  by  law  should  also  be  made  regu- 
larly to  the  state  health  department. 

THE  MODERN   THEORY   OF  INFECTION 

The  great  advances  in  sanitary  science  in  the  past  few 
years  have  brought  out  the  following  principles,  which 
are  fundamental  to  all  scientific  considerations  of  the 
nature  and  transmission  of  infection.  These  principles 
are  largely  antagonistic  to  the  older  and  now  disproved 
theories  of  disease. 

1.  Communicable  diseases  are  caused  by  definite  and 
specific  organisms  (bacteria,  protozoa,  etc.),  which  are 
transmitted  from  person  to  person  in  various  ways.  Many 
of  these  organisms  have  been  isolated  and  identified;  of 
others,  not  yet  isolated,  the  existence  is  inferred  by  the 
characteristics  of  the  disease. 

2.  Cases  of  such  disease  never  arise  spontaneously  (out 
of  decay,  etc.,  as  once  thought);  the  causative  organism, 
derived  from  a  previous  case  of  the  disease,  must  always 
be  present. 


COMMUNICAI'.IJ';    DISKASK  IO7 

3.  However,  it  is  now  a  recognized  fact  lliaL  the  presence 
of  the  organism  does  not  always  [)roduce  the  disease;  in 
other  words,  pathogenic  organisms  may  often  be  harbored 
by  persons  who  exhibit  few  or  no  signs  of  the  disease. 

This  last  statement,  involving  the  theory  of  mild  or 
unrecognized  ("missed")  cases  and  "carriers,"  requires 
some  explanation.  It  is  known  that  the  various  pathogenic 
organisms  vary  in  virulence;  also,  that  the  human  subject 
varies  in  resisting  powers.  These  facts  were  roughly  formu- 
lated several  years  ago  by  Dr.  Theobald  Smith  as  follows: 

in  which  D  =  the  intensity  of  the  disease,  M  =  the  strength 
of  the  microbic  attack  and  V  =  the  specific  vital  resistance 
of  the  person  attacked;  the  greater  the  infection  and  the 
lower  the  vital  resistance,  the  greater  the  intensity  of  the 
disease.  The  developments  of  more  recent  years  have 
brought  out  clearly  what  might  theoretically  have  been 
inferred  from  the  formula,  viz.,  that  there  are  all  degrees 
of  intensity  of  disease,  ranging  from  the  most  severe  down 
to  that  so  low  that  no  disease  can  be  detected.  In  other 
words,  one  subject,  infected  with  a  highly  virulent  strain 
of,  say,  B.  typhosus,  or  having  a  very  low  vital  resistance, 
may  exhibit  a  highly  severe  case  of  typhoid  fever;  while 
another  subject,  also  infected,  but  with  a  B.  typhosus  of 
low  virulence,  or  else  having  high  resistive  power,  may  not 
exhibit  any  symptoms  whatever.  A  person  of  the  latter 
class,  who,  without  exhibiting  symptoms,  harbors  and 
sheds  off  organisms  of  a  kind  ordinarily  pathogenic,  is 
known  as  a  carrier.  A  person  standing  between  the  two 
extremes,  exhibiting  some  more  or  less  mild  symptoms,  but 
not  a  typical  case  of  the  disease,  would  be  an  unrecognized 
or  missed  case.  It  is  obvious  that  the  last  two  classes  of 
cases  are  highly  dangerous  factors  in  the  spread  of  com- 
municable diseases;   much  more  so  in  fact  than  the  recog- 


loS  A  MANUAL   FOR  HEALTH  OFFICERS 

nized  cases  which  arc  under  surveillance,  for  the  latter  —  if 
the  surveillance  is  adequate  —  are  of  practically  no  danger. 
Some  authorities  hold  that  the  chief  part  in  the  spread  of 
many  of  the  common  communicable  diseases  is  played  by 
carriers  and  missed  cases.  And  indeed,  if  we  include  with 
the  missed  cases  the  effect  of  cases  in  early  but  infective 
stages  of  the  disease,  not  yet  recognized,  the  combined 
eflfect  of  carriers,  unrecognized  cases  and  incipient  cases 
accounts  fully  for  the  continuance  of  communicable  diseases 
even  in  communities  where  the  surveillan,ce  of  known  cases 
is  beyond  criticism. 

Since,  then,  "the  clinical  manifestations  of  an  infection 
may  vary  from  the  typical  description  of  the  text-book  to 
the  very  minimal  dimensions  which,  possibly,  only  sero- 
logical analysis  can  detect"  (Ledingham  and  Arkwright), 
the  continuance  and  spread  of  a  number  of  the  communicable 
diseases  is  due  to  the  following  classes  of  infected  persons: 

1.  Carriers  (no  symptoms). 

2.  Unrecognized  {missed)  cases  (mild  or  atypical  symp- 
toms) . 

3.  Incipient  but  infective  cases  (undeveloped  symptoms). 

4.  Recognized  {reported)  cases  (known  by  more  or  less 
typical  symptoms  or  bacteriological  test). 

To  these  might  be  added  a  small  class,  chiefly  of  the 
minor  infections,  which  are  recognized  by  family  or  physi- 
cian but  not  reported  as  required  by  law. 

THE   CARRIER  PROBLEM 

The  other  classes  need  no  special  comment,  but  the 
carriers  require  special  remark.^  We  may  preface  our  re- 
marks by  saying  that,  of  those  persons  classed  as  carriers 
in  the  widest  sense  of  the  term,  by  no  means  all  carry  viru- 
lent germs.     Some  strains  of  the  diphtheria  bacillus,  for 

^  For  a  detailed  treatment  of  the  subject  of  carriers  see  Ledingham 
and  Arkwright,  "  The  Carrier  Problem  in  Infectious  Diseases,"  London, 
1912. 


COMMUNICABLE   DIST^ASE  IO9 

instance,  arc  non-virulent,  as  can  be  prf)V(;cl  by  laboratory 
tests  on  animals.  While  this  is  a  forlimate  fact,  it  some- 
what complicates  the  matter,  for  it  is  not  always  feasible 
to  make  the  tests  necessary  for  distinguishing.  In  our 
discussion  of  carriers  we  shall  assume  that  most  are  carriers 
of  virulent  germs  and  that  all  are  at  any  rate  suspicious. 

There  are  in  general  two  kinds  of  carriers.  First,  those 
who  have  had  a  recognized  attack  after  which  the  person 
continues  to  harbor  and  shed  off  the  germ;  these  are 
the  chronic  carriers,  to  the  agency  of  which  a  number  of 
epidemics  have  been  traced  in  recent  years.  Chronic 
carriers  are  not  infrequently  "intermittent"  carriers,  i.e., 
there  are  periods  when  they  are  shedding  germs  and  periods 
when  they  are  not;  this  is  a  fact  of  special  importance 
when  a  search  is  being  made  for  carriers,  for  a  person  ex- 
amined during  a  non-shedding  period  may  show  negative 
results  and  be  let  off  without  suspicion.  Secondly,  there 
are  persons  who  become  infected  without  showing  any 
symptoms  and  harbor  the  germ  for  a  short  time  without 
apparent  ill-effects  to  themselves;  these  are  called  by 
recent  authorities  transitory  carriers. 

As  to  the  frequency  of  carriers  of  the  various  diseases : 

Even  when  diphtheria  is  not  prevalent  i  per  cent  of  the  population 
may  be  carrying  the  bacilli,  and  during  outbreaks  the  number  may  be 
several  times  greater.  Probably  25  per  cent  of  all  typhoid  fever  cases 
excrete  bacilli  for  some  weeks  after  convalescence,^  and  it  is  estimated 
that  from  I  in  500  to  i  in  250  of  the  population  are  chronic  carriers. 
.  .  .  There  is  no  evidence  that  there  are  many  carriers  of  measles  or 
smallpox.2 

The  same  authority  estimates  that  20  to  50  per  cent  of 
the  population  carry  pneumococci  and  that  the  influenza 
bacillus  is  as  widely  distributed.     In  epidemics  of  cerebro- 

*  12  per  cent  (10  in  86  cases)  have  been  found  to  be  carriers  three 
months  after  defervescence  (experiments  of  Semple  and  Greig,  1908). — 
J.  S.  M.     (Cf."  however  p.  200  of  present  volume.) 

'  Chapin,  "  Sources  and  Modes  of  Infection,"  1912,  p.  132. 


no  A  MANUAL   FOR   HEALTH  OFFICERS 

spinal  fever  the  carriers  may  be  ten  to  thirty  times  as  nu- 
merous as  cases.  In  yellow  fever,  and  especially  in  malaria, 
carriers  may  be  numerous.  In  one-third  to  one-half  the 
recovered  cases  of  cholera  the  vibrio  may  be  detected  for 
more  than  ten  days,  though  persistence  over  one  month 
is  very  exceptional  (Lcdingham  and  Arkwright) .  In 
dysentery  there  are  doubtless  numerous  carriers;  this 
disease  being  comparable  with  typhoid  fever,  though  the 
persistence  of  infection  appears  not  to  be  so  long.  On  the 
latter  two  diseases  there  is  comparatively  little  evidence. 
Scarlet  fever  seems  to  be  comparable  to  diphtheria  in  num- 
bers of  carriers.  The  many  only  partly  cured  cases  of 
gonorrhoea  and  syphilis  may  be  classed  as  carriers. 

While  the  data  on  carriers  are  by  no  means  full  (espe- 
cially in  those  diseases  of  which  the  causative  germ  is  un- 
known) the  evidence  shows  the  great  part  which  they  must 
play,  and  explains  the  failure  of  the  present  isolation  meas- 
ures to  obliterate  the  common  communicable  diseases. 
The  presence  or  possibility  of  carriers  and  missed  cases 
must  always  be  borne  in  mind  by  the  health  officer.  It  is 
in  this  direction  that  future  progress  in  control  methods  is 
to  be  looked  for. 

In  the  possible  cure  of  carriers  little  advance  has  as  yet 
been  made.  In  typhoid  fever  the  germ-bearing  urine  may 
be  internally  disinfected  by  means  of  the  drug  urotropin, 
which  is  useful  both  in  diminishing  the  incidence  of  the 
bacilluria  and  in  curing  it  when  established.  When  germs 
exist  in  the  nose  and  throat  it  is  possible  that  their 
numbers  and  the  amount  of  danger  may  be  diminished  by 
the  use  of  antiseptic  sprays  and  gargles  (e.g.,  hydrogen 
peroxide),  both  by  the  carrier  and  by  persons  in  association 
with  him,  or  by  special  medical  treatment  to  cleanse  and 
disinfect  the  crypts  of  the  tonsils.  The  efficacy  of  such 
measures  for  ridding  the  throat  of  germs  does  not,  how- 
ever, appear  as  yet  to  be  thoroughly  established. 

The  supervision  of  carriers  is  a  difficult  matter,  but  one 


COMMUNICABLE   DISEASE  III 

now  recognized  as  a  duty  of  health  authorities.^  In  the 
case  of  carriers  of  diphtheria,  where  the  germs  usually  dis- 
appear (or  may  be  made  to  disappear)  in  a  few  days,  iso- 
lation is  feasible,  especially  with  school-children.  There 
are,  however,  two  kinds  of  carriers:  (i)  those  existing  in 
the  general  population  and  giving  no  history  of  having 
been  in  contact  with  a  sick  person;  such  are  usually  carriers 
of  germs  of  little  or  no  virulence;  (2)  those  who  have  had 
the  disease  or  who  have  been  in  recent  association  with 
cases;  these  are  the  chief  carriers  of  virulent  germs  and  the 
class  most  to  be  watched  by  the  health  officer.  Thus  it  is 
not  feasible  to  isolate  all  carriers  —  say  of  diphtheria  —  in 
a  community,  though  it  is  feasible  to  search  out  and  isolate 
all  school-children  carriers  in  association  with  a  known  case 
of  the  disease.  In  the  former  case  the  isolation  would  be 
in  many  of  the  cases  needless  if  not  impracticable,  but  in 
the  latter  case  we  are  isolating  and  excluding  from  school 
presumably  virulent  carriers  in  the  class  in  which  diph- 
theria is  most  easily  spread,  viz.,  children  of  school  age. 

When  the  condition  of  germ  carriage  persists  a  long  time, 
as  in  typhoid  fever,  it  is  practically  impossible  closely  to 
restrain  the  carrier.  In  such  cases  it  seems  best  to  warn 
the  carrier  as  to  the  danger  of  infecting  other  persons, 
to  instruct  him  as  to  habitual  and  scrupulous  cleanliness 
of  the  hands,  and  to  maintain  a  sufficient  degree  of  sur- 
veillance over  his  movements  to  see  that  he  does  not  en- 
gage in  handling  foodstuffs  or  otherwise  spread  the  disease. 
The  last  requirement  would  necessitate  his  submitting  at 
certain  intervals  to  some  sanitary  authority  for  bacterio- 
logical examination  of  discharges  and  renewal  of  instruc- 
tions. Since  such  carriers  may  remove  from  towns  or  even 
from  the  state,  such  surveillance  might  perhaps  best  be  exer- 
cised by  state  health  authorities  in  cooperation  with  one 
another. 

^  Cf.  Sawyer,  "  The  Prevention  of  Carriers,"  Am.  Jour.  Pub.  Health, 
1914,  vol.  IV,  no.  3,  p.  217. 


112  A  MANUAL  FOR  HEALTH  OFFICERS 

It  is  of  the  greatest  importance  that  local  health  author- 
ities be  constantly  on  the  lookout  for  carrier  cases  in  the 
diseases  in  which  bacteriological  methods  are  available,  — 
i.e.,  especially  diphtheria  and  typhoid  fever.  When  such 
cases  are  discovered  they  may  be  dealt  with  locally  or  — 
as  suggested  above  —  in  cooperation  with  the  state  author- 
ities. There  should  also  be  a  steady  effort  —  especially 
through  the  extension  of  medical  inspection  in  schools  and 
even  in  dwellings  in  which  known  cases  exist,  and  through 
extension  of  bacteriological  diagnosis  —  to  detect  those 
mild  and  atypical  cases  which  would  otherwise  be  missed 
cases.  It  must  be  remembered  that  physicians  sometimes 
fail  to  report  mild  cases,  yet  these  (with  the  carriers)  are 
just  the  class  which  are  most  potent  in  spreading  disease 
and  most  in  need  of  effective  control. 

THE   SOURCES   AND   MODES   OF  INFECTION 

SOURCES  OF  INFECTION 

The  causative  organisms  of  the  various  communicable 
diseases  are  shed  off  in  the  excreta  of  the  patient  (e.g., 
typhoid  fever),  in  the  secretions  of  the  upper  respiratory 
passages  (diphtheria,  scarlet  fever),  in  the  sputum  coughed 
up  from  the  lungs  (pulmonary  tuberculosis),  or  in  the 
products  of  sores  (venereal  disease).  The  desquamation 
(scales)  from  the  skin  may  be  infectious  (e.g.,  in  smallpox).^ 
The  germs  may  also  exist  free  in  the  blood  of  the  patient 
and  be  carried  to  the  victim  through  the  medium  of  a 
blood-sucking  insect  (e.g.,  malaria,  infantile  paralysis). 

MODES  OF  TRANSMISSION 

Infection  may  be  conveyed  from  person  to  person  in  the 

following  ways: 

^  Contrary  to  former  belief,  modern  evidence  indicates  that  the 
desquamation  plays  little  or  no  part  in  the  transmission  of  scarlet  fever 
and  measles.  These  diseases  may  be  classed  with  diphtheria  as  being 
spread  probably  entirely  by  the  secretions  from  the  nose,  throat,  respir- 
atory passages  and  ear.     (Cf.  pp.  148,  151.) 


COMMUNICABLE   DISEASE  II3 

I.  Contact.  —  By  contact  injection  is  meant  the  transfer- 
ence of  infectious  matter  from  person  to  person  directly  and 
immediately,  or  nearly  so}  For  "contact  infection"  in 
this  sense  it  is  not  necessary  to  have  the  actual  touching  of 
the.  person  which  the  terms  "contact"  and  "contagious" 
are  popularly  taken  to  signify. 

Contact  infection  is  the  most  obvious  mode  of  transmission  of  ihe 
infectious  diseases  .  .  .  the  evidence  is  that  it  is  the  chief  mode.  .  .  . 
If  contact  infection  can  explain  epidemiological  phenomena,  there  is 
no  occasion  for  assuming  the  growth  of  pathogenic  germs  outside  of  the 
body,  or  of  infection  by  fomites  or  infection  by  air,  or  any  other  similar 
theory,  and  no  such  theory  should  be  adopted  as  a  working  hypothesis 
unless  pretty  strong  evidence  can  be  brought  to  its  support.     (Chapin.) 

Just  how  does  contact  infection  take  place?  The  con- 
tact may  be  of  the  perfectly  direct  type,  as  in  venereal 
transmission,  but  the  more  or  less  indirect  types  are  of 
more  importance  to  the  sanitarian.  There  are  countless 
ways  in  which  unseen  but  dangerous  amounts  of  discharges 
—  oral,  nasal,  intestinal,  urinary,  etc.  —  may  be  passed 
from  person  to  person.  The  starting  point  is  the  infec- 
tious person,  whether  he  be  a  recognized  patient  or  a 
carrier;  the  ending  point  is  the  portal  of  infection  of  some 
other  person  —  usually  the  mouth.  "Perhaps  90  per  cent 
of  all  infections  are  taken  into  the  body  through  the  mouth  " 
(Rosenau),  directly  from  the  fingers  or  with  food  or  drink. 

Among  specific  factors  in  contact  infection,  fingers  play 
the  chief  part.  The  fingers  of  all  persons,  both  sick  and 
well,  readily  become  contaminated  with  the  various  dis- 
charges,—  much  more  readily  and  frequently  than  is  gen- 
erally imagined.  From  Chapin,  who  presents  the  evidence 
in  detail,  the  following  extracts  (as  well  as  the  one  above) 
are  taken. ^ 

1  Important  Note.  —  Whenever  the  term  contact  as  a  mode  of  in- 
fection is  used  in  this  book,  it  is  to  be  taken,  not  in  the  limited  popular 
sense,  but  in  the  above  special  sense. 

2  "  Sources  and  Modes  of  Infection,"  1912. 


114  A  MANUAL  FOR  HEALTH  OFFICERS 

First,  as  to  finger  contamination  with  excreta: 

It  appears  that  the  fingers  of  human  beings,  and  secondarily  every- 
thing that  the  fingers  touch,  are  frequently  contaminated  with  excre- 
mental  matter.  ...  It  appears  that  the  fingers  of  careful  people, 
and  even  of  trained  nurses,  are  infected  in  this  manner.  ,  .  .  There 
is  much  evidence  that  this  mode  of  transference  is  an  important,  if  not 
the  most  important,  factor  in  the  spread  of  [typhoid  fever]. 

Again,  as  to  contamination  with  the  secretions  of  the 
nose  and  mouth  and  with  the  sputum: 

If  one  takes  the  trouble  to  watch  for  a  short  time  his  neighbors,  or 
even  himself,  unless  he  has  been  particularly  trained  in  such  matters, 
he  will  be  surprised  to  note  the  number  of  times  that  the  fingers  go  to 
the  mouth  and  the  nose.  .  .  .  Who  can  doubt  that  if  the  salivary 
glands  secreted  indigo  the  fingers  would  continually  be  stained  a  deep 
blue,  and  who  can  doubt  that  if  the  nasal  and  oral  secretions  contain 
the  germs  of  disease  these  germs  will  be  almost  continually  found  upon 
the  fingers?  ...  In  this  universal  trade  in  human  saliva,  the  fingers 
not  only  bring  foreign  secretions  to  the  mouth  of  their  owner,  but  there 
exchanging  them  for  his  own,  distribute  the  latter  to  everything  that 
the  hand  touches. 

But  there  are  also  other  modes  of  contact  infection: 

Another  important  vehicle  of  transfer  must  be  the  common  drink- 
ing cup.  .  .  .  The  mouth  is  put  to  numberless  improper  uses  which 
may  result  in  the  spread  of  infection.  It  is  used  to  hold  pins,  string, 
pencils,  paper  and  money.  .  .  .  Children  "  swap  "  apples,  cake  and 
lollipops.  .  .  .  Children  have  no  instinct  of  cleanliness,  and  their 
faces,  hands,  toys,  clothing  and  everything  that  they  touch  must  of 
necessity  be  continually  daubed  with  the  secretions  of  the  nose  and 
mouth.  It  is  well  known  that  between  the  ages  of  two  and  eight  years 
children  are  more  susceptible  to  scarlet  fever,  diphtheria,  measles  and 
whooping  cough  than  at  other  ages,  and  it  may  be  that  one  reason  for 
this  is  the  great  opportunity  that  is  afforded  by  their  habits  at  these 
ages  for  the  transfer  of  the  secretions.  Infants  do  not  of  course  mingle 
freely  with  one  another,  and  older  children  do  not  come  in  such  close 
contact  in  their  play,  and  they  also  begin  to  have  a  little  idea  of  clean- 
liness. 

Another  variety  of  contact  infection  is  "droplet  infection " 
through  the  spray  and  droplets  thrown  out  of  the  mouth 
and  nose  in  coughing,  sneezing  and  loud  speaking.     Such 


COMMUNICABLE   DISEASE  115 

infection  may  take  effect  within  a  short  radius  —  say  five 
or  six  feet  from  the  person  —  much  more  rarely  in  more 
distant  parts  of  the  room. 

Food  and  drink,  and  otlier  articles  may  readily  become 
infected,  and  if  these  convey  an  immediate  infection,  it 
may  properly  be  regarded  as  a  kind  of  contact. 

Persons  may  act  as  "go-betweens,"  conveying  infection 
—  without  themselves  having  the  disease  —  from  sick  to 
well;  this  is  a  kind  of  indirect  contact  infection.  They 
may  also  convey  by  acting  as  carriers  in  the  true  sense. 
Nurses  of  communicable  disease  must  therefore  be  regarded 
as  potentially  infectious. 

Such  considerations  apply  to  the  whole  community  and 
explain  why  diseases  spread  by  contact  readily  go  through 
a  family  but  do  not  so  readily  pass  between  families  having 
no  direct  association.  They  also  show  why  carriers  and 
missed  cases  in  a  community  are  potent  means  —  frequently 
the  chief  means  —  of  spreading  disease. 

In  arguing  the  importance  of  contact  infection  relatively 
to  other  modes  Chapin  adduces  two  points  of  evidence: 
"the  restriction  of  scarlet  fever  and  diphtheria  to  single 
families  in  the  same  house,  and  the  success  of  certain  hos- 
pitals in  preventing  cross-infection,  when  contact  infection 
is  strictly  guarded  against." 

The  preventives  of  contact  infection  at  large  are  evident. 
Personal  cleanlmess  is  the  prime  desideratum  and  should  be 
taught  and  encouraged  so  far  as  practicable  by  health  and 
school  authorities.^  The  care  of  the  hands  is  especially 
important.  The  point  is  emphasized  in  a  popular  manner 
in  the  following:  - 

THE   IIMPORTANCE   OF   KEEPING   HANDS   CLEAN 
Probably  the  commonest  way   in  which  infections  are  implanted 
within  our  bodies  is  from  hand  to  mouth. 

'  See  rules  on  p.  263. 

^  Bull.,  Chicago  School  of  Sanitary'  Instruction,  Nov.  i,  1913. 
Cf.  p.  585  of  present  volume. 


Il6  A  MANUAL   FOR  HEALTH  OFFICERS 

Our  hands  are  more  or  less  constantly  coming  in  contact  with  in- 
fectious matter  and  they  are  more  or  less  constantly  going  to  our 
mouths;  if  not  into  them  they  handle  and  infect  the  things  which  are 
put  into  them. 

It  is,  therefore,  intensely  important  that  we  shall  always  keep  our 
hands  as  clean  as  possible  by  frequent  washing. 

Hand  washing  is  necessary: 

Immediately  before  eating. 

Immediately  before  handling  foodstuflfs,  in  course  of  preparation  or 
serving. 

Immediately  after  necessary  toilet  attentions. 

Immediately  after  handling  the  sick  or  articles  from  a  sick  room. 

Immediately  after  handling  any  dirty  article. 

Persons  charged  with  the  preparation  or  handling  of  foodstuffs  and 
those  engaged  in  the  care  of  the  sick  should  be  especially  careful  about 
their  hands.  A  cook  with  dirty  hands  is  liable  to  infect  every  person 
who  eats  the  foods  she  handles.  A  nurse  with  infected  hands  can 
readily  spread  disease. 

In  washing  give  special  attention  to  the  cleansing  of  the  spaces  under 
the  fingernails.  Use  lots  of  soap,  warm  water  and  a  good  hard  bristle 
brush. 

Keep  your  hands  clean  and  you  will  avoid  many  unnecessary  infections. 

Look  to  your  cook's  hands  —  that's  a  test  of  her  efficiency  and  of 
your  safety  at  her  hands. 

Immediately  dismiss  a  nurse  who  is  careless  about  the  condition  of 
her  hands. 

These  are  simple,  every-day  matters  —  but  they  count  mightily. 
Dirty  hands  will  hand  you  trouble. 

Again,  in  special  relation  to  typhoid  fever,  the  following: 

As  far  as  unclean  hands  are  concerned,  our  course,  as  regards  typhoid 
infection,  would  seem  to  resolve  itself  into  the  two  following  proposi- 
tions: first,  that  inasmuch  as  no  person  can  be  absolutely  certain  that 
he  is  not  a  typhoid  carrier  (for,  of  course,  it  is  well  known  that  a  healthy 
human  being,  and  especially  those  attendant  upon  typhoid  patients, 
may  become  a  temporary  typhoid  carrier,  even  though  he  has  not 
suffered  from  the  disease  itself)  every  one  should,  as  far  as  possible, 
wash  his  hands  with  scrupulous  care  after  any  possible  contamination 
with  feces  or  urine,  and,  secondly,  that  no  one  should  think  of  handling 
food,  either  for  his  own  use,  or  for  others,  without  carefully  washing 
his  hands.^ 

^  Richardson,  "  Dirty  Hands  and  Typhoid  Fever,"  Am.  Jour.  Pub. 
Health,  1914,  vol.  iv,  no.  2,  p.  140. 


COMMUNICABLE   DISEASE  II7 

The  simple  precaution  oi  following  the  above  rules 
would  automatically  protect  the  individual  and  his  neigh- 
bors and  nearly  if  not  entirely  eliminate  certain  of  the 
common  communicaljle  diseases.  But  so  long  as  such  pre- 
cautions arc  neglected  by  the  vast  majority  of  the  public, 
just  so  long  will  disease  continue  to  be  spread  by  carriers 
and  missed  cases. 

In  the  sick-room  and  hospitals  such  considerations  apply 
with  special  force.  There  scrupulous  cleanliness,  with  the 
use  of  disinfectants  as  an  additional  safeguard,  must  con- 
stantly be  practiced. 

As  an  example  of  the  modern  "aseptic"  method  of  pre- 
venting contact  infection  in  common  diseases,  and  prac- 
tical disregard  of  air  infection,  the  following  remarks, 
referring  to  the  Providence  City  Hospital,  may  be  quoted: 

The  authorities  in  the  Providence  institution  believe  that  air-borne 
germs  play  a  very  small  part  in  the  dissemination  of  disease,  and  the 
barrier  that  is  set  up  against  the  spread  of  infection  is  literally  a  "  fight 
at  the  bedside  of  the  patient."  The  figures  show  that  this  has  been 
done  with  success.  .  .  . 

[Gowns]  are  put  on  when  there  is  occasion  to  approach  closely  to  the 
bed  or  touch  the  patient,  and  taken  off  and  the  hands  washed  before 
leaving  that  patient.  ...  If  a  visitor  touches  anything  in  the  room 
the  hands  must  be  washed.  For  measles  and  one  or  two  other  maladies 
whose  precise  method  of  infection  is  not  understood  the  disinfectant  is 
used  after  washing.   .  .  . 

The  features  of  the  Providence  City  Hospital,  then,  that  are  novel 
are  these,  that,  in  a  hospital  for  communicable  diseases,  the  fight  is 
made  absolutely  at  the  bedside  of  the  patient,  that  the  infection  is 
considered  as  stopping  there.  The  corridors  are  believed  to  be  as  free 
from  contagion  as  those  of  any  general  hospital.  And  even  into  the 
wards  and  rooms  a  Citj'  Father  in  discharge  of  his  duties  of  inspection 
could  safely  go.  Ingress  and  egress  from  the  hospital  are  practically 
free  and  in  fact  much  of  the  machinery  and  red-tape  that  surrounds 
hospitals  in  general  is  eliminated  in  Providence.  And  there  is  further- 
more the  belief  in  the  cleansing  properties  of  soap  and  water  that  ob- 
tains almost  nowhere  else.  Walls  that  may  be  thoroughly  cleaned, 
floors  of  battleship  linoleum  that  is  resilient,  durable  and  hygienic 
and  the  cleansing  of  wooden  floors  so  well  that  infection  from  the  dust 


Il8  A  MANUAL   FOR  HEALTH  OFFICERS 

is  negligible,  furnish  an  outfit  that  supplements  the  care  practiced  by 
all  who  enter.  .  .  .  ^ 

Of  course  it  must  be  remembered  that  the  above  refers 
to  a  hospital  where  aseptic  measures  not  generally  prac- 
ticable in  private  dwellings  may  be  enforced.  With  com- 
municable disease  in  dwellings  disinfectants  must  be  relied 
upon  to  remedy  deficiencies  in  the  cleanliness  which  is  so 
strongly  argued  above,  but  which  in  general  sanitary  prac- 
tice is  as  difficult  to  obtain  as  it  is  simple  to  recommend. 

2.  Food  and  Drink.  —  Various  articles  of  food  and  drink 
readily  act  as  vehicles  of  infection,  and  may  be  classed  as 
second  only  to  contact  infection  in  importance.  Milk,  on 
account  of  its  liability  to  contamination  and  its  property 
of  nourishing  or  at  least  preserving  pathogenic  organisms, 
is  especially  liable;  as  is  also  water,  which  is  readily  polluted 
and  may  scatter  infection  broadcast.  Many  serious  epi- 
demics have  been  traced  to  milk  and  water  infection. 
Hence  such  supplies  are  properly  subjected  to  special  pro- 
tection. This  mode  is,  of  course,  essentially  an  extension 
of  contact  infection  to  a  wider  circle  of  effect,  so  that  meas- 
ures against  contact  infection  also  help  to  protect  food  and 
water  supplies. 

3.  Fomites.  —  If  germs  are  transferred  from  person  to 
person  by  means  of  some  object  directly  and  without 
delay  —  or  nearly  so  —  the  process  is  called,  as  already 
stated,  contact  infection.  But  if  such  objects  retain  infec- 
tion for  some  time  and  then  transmit  it  they  are  known  as 
fomites. 

A  toy  used  by  a  diphtheria  patient  and  sent  to  a  distant  town  and 
there  giving  rise  to  the  disease,  the  dress  of  a  scarlet  fever  patient  put 
away  for  weeks  or  months  and  brought  out  only  to  cause  another  case, 
a  library  book  carrying  the  infection  of  smallpox  from  one  household 
to  another,  .  .  .  and  the  various  objects  in  a  room  lately  occupied  by 
a  case  of  any  contagious  disease  giving  rise  to  the  same  infection  in 

1  Boston  Transcript,  "  The  Clinic  "  column,  May  28,  1913.  Cf. 
Chapin,  "  Studies  in  Air  and  Contact  Infection  at  the  Providence  City 
Hospital,"  Am.  Jour.  Pub.  Health,  1912,  vol.  ii,  no.  3,  p.  135. 


COMMUNiCAFJIJC    DFSKASE  IIQ 

newcomers,  would  all  be  recognized  as  fomilcs.  The  cup  which  carries 
the  moist  saliva  from  one  school  child  to  another,  the  borrowed  pencil 
which  transfers  the  fresh  syphilitic  virus  from  lip  to  lip,  and  the  urine- 
moistened  closet  seat  which  infects  the  fingers  and  then  the  mouth  of 
the  next  user,  are  not  thought  of  as  fomites  but  as  the  necessary  media 
for  that  intimate  mode  of  disease  transference  which  is  coming  to  be 
called  contact  infection.  This  distinction  between  the  two  classes  of 
bearers  of  infection  is  somewhat  arbitrary,  and  not  very  definite,  but 
is  eminently  practical.  ...  By  infection  by  fomites  is  meant  a  trans- 
ference of  infecting  material  on  objects  under  such  conditions  that 
considerable  time  elapses,  days  at  least,  usually  weeks,  sometimes 
months.^ 

Fomites  infection  as  thus  defined  is  considered  by 
modern  authorities  to  be  of  much  less  importance  than 
was  formerly  supposed.  About  the  only  exceptions  to  this 
statement  are  anthrax  and  tetanus  (q.v.).  Chapin  sum- 
ming up  the  evidence  concludes  that  "there  is  no  good 
epidemiological  evidence  that  any  diseases  except  those  due 
to  spore-forming  bacteria  are  to  any  great  extent  trans- 
mitted by  fomites,"  and  that  "other  modes  of  transmission 
so  much  more  satisfactorily  account  for  the  spread  of 
disease,  that  there  seems  to  be  really  little  opportunity  for 
infection  by  fomites." 

In  any  event  measures  which  prevent  contact  infection 
also  prevent  any  possibility  of  fomites  infection  which  may 
exist. 

4.  Air.  —  Air  was  formerly  considered  the  chief  vehicle 
of  infection,  but  now,  like  fomites,  it  is  regarded  as  of  far 
less  importance  than  tradition  has  held.  "There  are  only 
two  diseases  of  man,  viz.,  smallpox  and  measles,  which 
may  possibly  be  air-borne,  in  the  sense  that  this  term  is 
generally  used.  .  .  .  The  more  the  transmission  of  the 
communicable  diseases  is  studied,  the  less  the  air  is  im- 
plicated." (Rosenau.)  Even  with  smallpox  and  measles 
there  is  a  great  deal  that  is  obscure,  and  strict  aerial  trans- 
mission does  not  appear  ever  to  have  been  clearly  demon- 
strated. 

^  Chapin,  op.  cit. 


I20  A  MANUAL  FOR  HEALTH  OFFICERS 

There  is  on  the  other  hand  evidence  that  air  transmission 
in  a  rough  sense  does  sometimes  occur  through  the  convey- 
ance of  germs  on  floating  atmospheric  particles  (dust  or 
droplets).  Droplet  infection,  however,  is  logically  allied 
to  contact  infection  (see  above).  As  for  the  theory  of 
transmission  by  dust,  it  is  supported  by  some  evidence, 
especially  in  regard  to  tuberculosis;  but  the  dangers  are 
apparently  relatively  small  —  at  any  rate  much  less  than 
was  formerly  thought. 

It  is  an  interesting  fact,  incidentally,  that  expired  air, 
once  thought  virus-laden,  is  proved  under  normal  condi- 
tions of  respiration  to  be  sterile. 

It  may  be  concluded  that  if  the  measures  necessary  to 
prevent  contact  infection  are  taken,  the  danger  of  infec- 
tion by  air  (including  dust),  with  the  possible  exceptions 
noted,  may  practically  be  disregarded.^ 

5.  Insects.  —  Infection  through  insects  is  a  mode  which 
stands  quite  distinctly  by  itself.  Malaria,  yellow  fever, 
plague,  and  other  diseases  are  transmitted  through  the 
bites  of  specific  insects,  which  act  in  such  cases  as  "inter- 
mediary hosts"  of  the  diseases.  The  insects  involved  are 
the  malaria  mosquito,  the  yellow  fever  mosquito,  the  plague 
flea,  etc.  Prevention  involves  suppression  of  the  insects 
and,  as  a  temporary  measure,  protection  of  the  patient  from 
access  by  them.  Flies  and  other  insects  may  also  convey 
infectious  material  mechanically,  as  on  their  legs,  but  this 
is  logically  classed  as  a  kind  of  contact  infection.  The 
ordinary  cockroach  has  recently  been  shown  capable  of  so 
conveying  infection. 

6.  Special  Modes.  —  Certain  special  modes  of  transmis- 
sion may  be  added.  Thus,  rabies  is  transmitted  directly 
by  the  bite  of  the  rabid! dog  or  other  animal;    anthrax  is 

^  The  subject  is  admirably  discussed  by  Chapin:  "The  Air  as  a 
Vehicle  of  Infection,"  Jour.  Am.  Med.  Assn.,  1914,  vol.  Ixii,  no.  6;  and 
"  The  Relative  Importance  of  Aerial  and  Contact  Infection,"  Trans. 
XV  Internal.  Congress  Hyg.  and  Demogr.,  1912,  vol.  IV,  pt.  I,  pp.  9-17- 


COMMUNICABLE  DISEASE  121 

most  often  transmitted  from  cattle  to  man  by  infection  of 
skin  lesions  by  the  bacteria  in  hides;  and  hookworm  is 
usually  contracted  through  contact  of  bare  feet  or  hands 
with  polluted  soil. 

When  third  persons  convey  infection  from  sick  to  well, 
it  may  either  be  by  contact  (e.g.,  by  medium  of  the  hands) 
or  such  persons  may  be  true  carriers  of  the  germ,  i.e.,  har- 
boring it  themselves. 

In  conclusion,  as  the  chief  mode  of  transmission  of  infec- 
tion we  must  rank  contact  in  the  broadest  sense  of  the  term. 
Milk  and  water  supplies  are  also  of  great  importance.  Then 
come  the  disease-bearing  insects,  which,  however,  are  some- 
what localized  in  distribution.  Lastly,  of  distinctly  minor 
importance  —  so  much  so  that  in  practice  they  can  be 
almost  entirely  disregarded  —  come  air  and  fomites  infec- 
tion as  commonly  understood;  for  it  has  been  shown  that 
much  of  the  supposed  air  and  fomites  infection  is  in  reality 
due  to  contact  and  the  other  modes  of  transmission.^ 

^  Valuable  evidence  as  to  the  importance  of  contact  and  the  relative 
non-importance  of  aerial  and  fomites  infection  is  found  in  the  ex- 
perience of  the  Providence  City  Hospital,  which  is  operated  on  the 
principles  advocated  by  Chapin.  In  that  institution  some  cases  are 
isolated  in  rooms  and  some  in  wards  with  mere  barriers,  to  act  as  warn- 
ings, between  the  beds.  The  rooms  open  into  a  common  corridor  and 
the  doors  are  always  open,  the  nurses  going  from  case  to  case.  No 
disinfecting  solutions  are  used  for  the  hands,  but  strict  cleanliness  of 
the  hands  and  aseptic  precautions  are  insisted  upon.  The  same  nurse 
attends  cases  of  different  diseases.  In  the  i8  months  ending  September 
I,  191 1,  there  were  but  7  cases  of  cross-infection  among  365  patients 
in  rooms.  "  These  figures,  which  show  fewer  cases  of  cross-infection 
than  In  many  isolation  hospitals  under  the  old  system,  make  strong 
evidence  against  the  theory  of  air-borne  infection.  ...  It  appears 
then  that  the  chief  means  of  spreading  infection  is  not  through  the  air 
or  by  means  of  fomites,  but  by  means  of  contact  either  with  carriers  or 
the  patients  themselves."  (Rpt.  Committee  on  Communicable  Dis- 
eases of  Am.  Pub.  Health  Assn.,  Am.  Jour.  Pub.  Health,  1912,  vol.  II, 
no.  2,  p.  119.)  Cf.  Doty,  "  The  Control  of  Disinfection  and  the  Influ- 
ence of  Infected  Rooms  and  Fomites  in  the  Dissemination  of  Various 
Infectious  Diseases,"  Trans.  XV  Intertiat.  Congress  Hyg.  and  Demogr., 
1912,  vol.  IV,  pt.  I. 


122  A  MANUAL  FOR  HEALTH  OFFICERS 

Summary.  —  The  following  summary  shows  some  of  the 
more  important  points  in  which  modern  practice  differs 
markedly  from  the  traditional: 

1.  Transmission  of  infection:  emphasis  to  be  placed 
upon  contact,  food,  drink  and  insects.  Air  and  fomites 
infection  of  little  or  no  importance. 

2.  Isolation:  value  lessened  by  presence  of  carriers  which 
escape  isolation;  has,  however,  a  definite  use  in  restriction 
or  spread  of  infection.  A  reasonable  isolation  adapted  to 
the  individual  case  usually  preferable  to  rigid  and  sweeping 
quarantine  regulations. 

3.  Disinfection:  chemical  disinfection  used  as  a  pre- 
caution additional  to  scrupulous  sick-room  cleanliness. 
Infectious  matter  to  be  destroyed  at  the  bedside;  terminal 
disinfection  of  comparatively  little,  where  any,  value. 

4.  Laboratory  methods:  increased  use  of  the  laboratory 
for  diagnosis,  treatment  and  prophylaxis  (through  sera), 
and  determination  of  time  of  release  of  cases  of  commu- 
nicable disease. 

5.  Chief  administrative  problems:  control  of  carriers 
and  of  incipient  and  missed  cases;  lack  of  exact  knowledge 
as  to  channels  of  infection. 

6.  Control  by  principles  rather  than  rules.  In  the  past 
it  has  been  the  practice  of  health  authorities  to  for- 
mulate inflexible  rules  for  the  control  of  communicable 
diseases.  Some  such  rules  are  practically  necessary,  yet 
to-day  we  see  that  good  judgment  in  the  health  official 
is  more  important  than  blind  adherence  to  traditional 
methods  provided  he  has  the  thorough  knowledge  of  public 
health  science  upon  which  to  base  that  judgment. 

A  public  health  official  should  be  practically  familiar  with  the  in- 
fectious diseases,  and  with  the  means  by  which  they  are  transmitted 
from  one  person  to  another,  and  he  should  not  accept  theories  relative 
to  the  latter  unless  they  are  supported  by  scientific  evidence.  He  must 
have  the  courage  of  his  convictions  in  his  efforts  to  protect  the  public 
health  and  should  carry  out  only  such  measures  as  are  reasonable  and 
practical.     Attempts   to   secure   complete   safety   by   unjustifiable   or 


COMMUNICAIil.K    I^FSIOASE  1 23 

spectacular  incthofls  usually  defeat  tlu;  end   in   view,  and  arc  not   in 
accord  with  modern  sanitation.  .  .  . 

Success  in  public  health  work  ...  is  frequently  obstructed  by 
attempts  to  follow  specific  rules  and  regulations  in  the  management  of 
outbreaks,  etc.,  instead  of  being  governed  by  the  principles  of  sanitary 
science,  a  practical  familiarity  with  which  will  enable  a  health  officer 
to  cope  intelligently  with  any  condition  or  emergency  which  may  pre- 
sent itself.  Specific  rules  and  regulations  never  accurately  fit  all  cases, 
and  if  followed  tend  to  make  a  health  officer  an  automaton.  Whereas, 
if  the  princii^lcs  upon  which  sanitary  science  is  founded  arc  fully  under- 
stood and  acted  upon,  but  comparatively  few  rules  or  regulations  are 
necessary.  A  policy  of  this  kind,  which  deals  in  a  practical  manner 
with  all  measures  relating  to  the  public  health,  causes  the  minimum 
amount  of  annoyance  to  the  public  and  to  commerce.^ 

I.   DISEASES    SPREAD    LARGELY   THROUGH 

SECRETIONS    OR    DISCHARGES    FROM 

NOSE,   THROAT   OR   MOUTH 

In  this  class  of  diseases  the  first  preventive  measure 
applied  to  known  cases  is  to  destroy  or  disinfect  the  discharges 
in  the  sick-room  and  without  delay.  This  must  be  done  by 
an  efficient  nurse,  who  observes  scrupulous  cleanliness  of  all 
objects  in  contact  with  the  patient,  and  especially  of  her 
own  hands.  The  latter  two  measures  we  shall  refer  to  here- 
after as  prophylactic  cleanliness.  As  an  additional  pre- 
'  caution,  association  with  the  patient  is  to  be  prevented 
through  isolation.  All  of  these  diseases  may  be  spread 
primarily  by  contact,-  and  secondarily,  in  some  instances, 
through  food  and  drink. 

We  shall  now  describe  what  is  meant  by  disinfection  and 
isolation,  so  that  it  will  not  be  necessary  to  repeat  the  details 
under  the  head  of  each  disease. 

Asepsis  and  Disinfection.  —  The  destruction  or  dis- 
infection of  the  infected  discharges  and  of  articles  infected 
by  them,  during  the  course  of  the  disease,  in  the  sick-room 
or  as  near  to  it  as  possible,  and  without  delay,  is  the  great- 

^  Doty,  "  Prevention  of  Infectious  Diseases,"  191 1,  pp.  20-22. 
^  See  note,  p.  113. 


124  A  MANUAL   FOR  HEALTH  OFFICERS 

est  single  measure  that  can  be  adopted  for  the  prevention 
of  the  spread  of  infection  from  the  individual  case.  If 
this  one  measure  were  thoroughly  carried  out,  in  com- 
bination with  proper  isolation  of  the  patient,  the  trans- 
mission of  disease  from  known  cases  would  be  reduced 
to  nil.  In  Appendix  A  will  be  found  detailed  instructions 
for  disinfection. 

The  necessity  for  such  immediate  and  direct  disinfection 
and  for  the  maintenance  of  a  clean  and  practically  germ- 
less  condition  of  the  nurse's  hands  should  be  impressed  by 
the  health  department  officer  who  establishes  the  isolation. 
The  processes  for  reaching  the  desired  results  should  be 
explained  in  detail  and  arrangements  made  as  to  the  vessels, 
etc.,  to  be  used.  Health  departments  should,  moreover, 
furnish  free  or  at  cost  the  disinfectants  needed,  as  other- 
wise families  are  likely  to  obtain  ineffective  materials  or 
stint  in  their  use. 

Isolation.  —  Isolation  of  the  patient  is  a  protective  meas- 
ure, the  value  of  which  rests  upon  the  fact  that  in  practice 
the  disinfection  of  all  discharges  cannot  be  insured,  and 
that  persons,  if  they  were  not  excluded  from  the  patient, 
would  become  infected  by  contact  with  the  patient  or  with 
undislnfected  discharges  or  articles  contaminated  by  them, 
both  of  which  are  common  to  sick-rooms.  Also,  as  in 
smallpox  and  measles,  a  slight  contact  with  the  patient  (or 
possibly  air  infection)  may  be  sufficient  to  result  in  trans- 
mission. 

The  following  may  be  taken  as  the  principal  points  of  a 
proper  isolation: 

I.  The  room  chosen  for  isolation  should  be  in  as  retired 
a  part  of  the  house  as  possible,  preferably  in  an  upper  story, 
away  from  living  and  dining  rooms  and  kitchen.  It  should 
contain  no  unnecessary  furnishings,  and  carpets,  curtains, 
upholstery  and  the  like  should  so  far  as  practicable  be 
removed. 

The  door  should  be  kept  closed  and  a  small  placard  may 


COMMUNTCM'.LK    DISEASE  125 

be  placed  upon  it  as  a  deterrent  to  cliilflrcn  ;iiul  f^llicr 
possible  intruders;,  this  will  serve  the  same  f)Lirpose  as  tlu; 
usual  disinfectant  sheet  over  the  door,  which  is  of  no  demon- 
strable value  (see  air  infection,  page  Ii9f.). 

The  sick-room  should  be  screened,  if  necessary,  to  ex- 
clude flies  and  other  insects.  Flics  in  and  about  the  sick- 
room should  be  killed  as  being  possibly  infected.  Animal 
pets  which  are  fondled  by  children  may  carry  infection. 
It  would  be  wise  to  give  pets  which  have  been  so  exposed  a 
thorough  washing.  They  may  be  isolated  with  the  patient 
provided  they  are  not  allowed  to  pass  out  and  mingle  with 
the  rest  of  the  family,  and  should  be  washed  at  the  close 
of  the  isolation.  Cats  should  be  regarded  with  suspicion 
as  they  are  known  to  become  occasionally  true  "carriers" 
of  diphtheria,  the  infection  being  seated  in  the  nose  of  the 
animal. 

2.  One  person  —  preferably  a  trained  nurse  —  should 
act  as  nurse  and  should  be  isolated  with  the  patient.  If 
the  mother  of  a  family  endeavors  to  act  as  nurse  and  at 
the  same  time  cook  and  care  for  well  children  in  the  family, 
she  is  likely  to  infect  the  latter  unless  extreme  care  is 
taken. 

Upon  the  nurse  devolves  the  responsibility  for  cleanli- 
ness and  disinfection,  and  for  maintaining  strict  isolation. 
If  she  has  to  leave  the  room  she  should  have  no  association 
or  contact  with  other  members  of  the  household.  Other 
persons,  with  the  exception  of  physician  and  clerg^'man, 
should  be  excluded. 

The  nurse  should  be  a  person  of  sufiEicient  intelligence 
and  should  be  instructed  in  detail  by  the  inspector.  Printed 
circulars  of  instruction  are  useful  for  educated  persons,  but 
cannot  in  any  case  dispense  with  personal  instruction. 

The  nurse  should  guard  against  "contact"  infection  of 
the  various  kinds  including  "droplet  infection."  Thor- 
ough washing  and  disinfection  of  the  hands  is  a  prime 
essential.     If  the  person  acting  as  nurse  cannot  be  isolated 


126  A  MANUAL  FOR  IIE.\LTH  OFFICERS 

with  the  patient,  she  may  wear  a  gown  or  wrapper  and  a 
head  covering  while  in  the  sick-room,  putting  it  off  at  the 
door  when  leaving  the  room.  Care  should  be  taken  in 
regard  to  possible  infection  of  the  bath-room  and  toilet, 
e.g.,  through  disposal  of  discharges.  Patient  and  nurse 
should,  if  possible,  have  a  bath  and  toilet  separate  from  the 
rest  of  the  family. 

The  nurse  -must  see  that  all  discharges  which  may  con- 
vey infection  are  promptly  disinfected  or  burned.  Articles 
(including  eating  utensils  and  remnants  of  food)  which 
may  be  infected  must  receive  similar  treatment.  The  dis- 
infection should  so  far  as  possible  be  performed  in  the  sick- 
room, but  it  may  be  more  convenient  to  place  dishes, 
bedding,  and  the  like  in  a  vessel  outside  of  the  door,  to  be 
disinfected,  e.g.,  by  boiling.  More  reliance  is  to  be  placed 
in  fire  and  heat  than  in  chemical  disinfectants,  which  may 
be  expensive,  dangerous,  inefficient,  or  not  adapted  to  use 
by  unskilled  persons. 

Finally,  if  a  proper  home  isolation  cannot  be  assured,  the 
patient  should  be  removed  to  the  isolation  hospital. 

Quarantine.  —  We  come  now  to  the  measures  which 
apply,  not  directly  to  the  patient,  but  to  the  persons  about 
him  and  to  the  dwelling  itself.^  Although  the  best  modern 
practice  lays  less  stress  on  quarantine  or  even  isolation  than 
on  proper  asepsis  and  bedside  disinfection,  nevertheless 
quarantine  measures,  especially  as  applied  to  possible 
carriers  in  the  family  of  the  patient,  arc  important.  The 
following  points  pertain  to  quarantine: 

^  The  terms  "  isolation  "  and  "  quarantine  "  are  frequently  confused. 
Isolation  (or  segregation)  refers  to  the  restrictions  directly  surrounding 
the  patient.  Quarantine  is  a  broader  term  which  covers  measures 
applied  to  the  premises  and  household.  The  terms  are  used  in  the 
present  chapter  in  those  senses.  Quarantine  in  a  still  broader  sense 
refers  to  restrictions  placed  on  an  area  of  some  magnitude.  Thus  there 
may  even  be  a  national  quarantine.  The  term  applies  in  a  special 
sense  to  the  measures  taken  at  ports  to  prevent  introduction  of  infec- 
tion from  foreign  ports  and  at  foreign  frontiers. 


COMMUNICABLE  DISEASE  127 

1.  It  is  customary  to  placard  both  front  and  rear  of  a 
quarantined  house  or  apartment,  with  the  warning  that 
visitors  arc  not  to  enter.  If  there  are  other  famihes  in  the 
same  house  —  e.g.,  a  tenement  —  it  is  usually  unnecessary 
and  impracticable  to  apply  the  quarantine  to  families  other 
than  the  one  in  question,  but  the  quarantine  of  that  family 
must  be  made  perfectly  clear.  The  placard  warns  persons 
not  to  pay  visits  or  associate  with  members  of  the  infected 
family,  and  the  rear  door  sign  is  a  special  warning  to  the 
milk  dealer. 

2.  Milk  bottles  should  not  be  permitted  to  enter  or  leave 
the  house  during  the  period  of  quarantine.  It  is  a  frequent 
custom  to  forbid  milk  dealers  to  leave  bottles  where  there 
is  a  placard,  but  to  pour  the  milk  into  a  pitcher  or  other 
vessel  put  out  by  the  family.  There  are  some  disadvan- 
tages in  this:  the  vessel  is  subject  to  contamination  and 
the  uncapping  of  the  milk  by  the  delivery  man  is  undesir- 
able. Hence  it  is  better  to  permit  milk  to  be  delivered  in 
bottles  to  quarantined  families,  with  the  proviso  that  no 
bottles  be  removed  by  the  dealer.  Then  at  the  termination 
of  the  quarantine  all  bottles  which  have  accumulated  are 
disinfected  (e.g.,  by  boiling)  under  the  supervision  of  the 
inspector,  and  returned  to  the  dealer.^ 

3.  In  the  restrictions  on  members  of  the  household  dis- 
cretion based  on  principle,  rather  than  rigid  rules,  is  re- 
quired. It  may,  however,  be  necessary  to  lay  down  certain 
rules  for  the  guidance  of  inspectors. 

The  chief  restrictions  usually  apply  to  children.  Under 
the  heads  of  the  various  diseases  will  be  indicated  the 
exclusion  measures  applicable  to  school  children;  those 
not  yet  of  school  age  should  be  restricted  correspondingly. 
Children  who  have  not  had  the  disease  may  sometimes 
be  sent  to  live  elsewhere  with  relatives  and  thus  be 
readmitted  to  school  sooner  than  if  they  stayed  at  home 

1  Rule  of  Mass.  Assn.  of  Boards  of  Health,  Am.  Jour.  Pub.  Health, 
1912,  vol.  ii,  no.  12,  p.  996. 


128  A  MANUAL  FOR  HEALTH  OFFICERS 

to  await  termination  of  tlie  case.  The  quarantine  of 
children  should  forbid  their  going  off  the  premises  or 
associating  with  children  of  other  families. 

If  isolation  is  good  the  restrictions  on  adult  members 
of  the  household  need  not  be  onerous.  Certain  members 
may  be  given  permits  to  leave  the  premises  to  go  to  work, 
purchase  supplies,  etc.  Working  persons  need  not  ordi- 
narily be  kept  from  work  unless  they  are  concerned  with 
the  handling  of  foods  capable  of  becoming  infected,  viz., 
cooks,  waiters,  bakers,  confectioners,  etc.  Such  persons 
may  be  required  to  live  away  from  home  during  the  period 
of  quarantine  unless  the  case  is  removed  to  the  hospital. 
As  regards  school-teachers,  conductors,  barbers  and  other 
persons  whose  work  involves  some  degree  of  personal  con- 
tact, if  the  isolation  is  good  there  seems  to  be  no  sufficient 
reason  for  keeping  such  persons  from  their  occupations. 
If  there  is  any  real  question  the  case  may  be  sent  to  the 
hospital  or  such  persons  may  go  to  live  elsewhere  during 
the  period  of  isolation.  Each  case  should  be  judged  on 
its  merits,  and  uncalled-for  hardship  should  not  be  imposed, 
bearing  in  mind  that  healthy  adults  rarely  act  as  conveyors 
of  disease  unless  the  degrees  of  contact  at  both  ends  of  the 
line  are  intimate. 

4.  As  to  other  families  in  the  same  house,  the  restrictions 
may  be  less  strict  and  should  be  based  upon  the  probable 
degrees  of  association  between  families.  The  children  are, 
of  course,  the  chief  consideration.  If  there  is  a  good  iso- 
lation of  the  case,  and  children  in  the  quarantined  family 
have  positively  not  been  exposed  and  keep  to  themselves, 
there  need  perhaps  be  no  restrictions  on  the  other  families. 
But  if  it  seems  possible  that  there  has  been  exposure,  the 
children  in  such  families  should  be  kept  out  of  school  until 
the  incubation  period  of  the  disease  has  expired  or  until 
(in  diphtheria)  negative  cultures  have  been  obtained.  On 
the  other  hand,  association  between  children  in  dififerent 
families  may  be   nearly  —  if  not  quite  —  as  intimate  as 


COMMUNICABLE    DfSKASE  1 29 

between  children  in  the  same  family.  If  any  c/mtinncl 
association  between  famiHes  is  suspected,  the  cliildren  from 
all  families  should  be  excluded  from  school  and  kept  on 
the  premises.  Adults  in  the  other  families  need  not,  as  a 
rule,  be  restricted,  but  may  be  warned  to  exercise  f)roper 
control  over  their  children.  Since  this  is  frequently  imprac- 
ticable, as  in  a  tenement,  much  the  better  plan  is  to  remove 
the  case  to  the  isolation  hospital.  A  loose  so-called  c^uaran- 
tine  of  a  large  number  of  persons  in  a  house  is  impracticable 
and  its  failure  subversive  of  authority.  Of  course,  in  all 
cases  members  of  associated  families  should  be  carefully 
watched  for  development  of  cases,  and  a  search  should  be 
made  for  carriers  and  unrecognized  cases  when  suspected. 
(For  specific  rules,  see  under  the  various  diseases.) 

//  an  effective  isolation  and  quarantine  cannot  he  obtained 
at  home  the  patient  should  be  removed  to  the  isolation  hospital 
and  possibly  infected  surfaces  and  articles  should  be 
promptly  disinfected  (see  Appendix  A).  Hospital  removal 
is  desirable  also  when  a  case  is  found  in  a  lodging-house  or 
institution.  Even  in  many  instances  where  home  isolation 
is  perfectly  feasible  there  are  protection  and  benefit  to  the 
community  and  family  and  advantages  to  the  patient  in 
proper  hospital  treatment  (see  later,  under  the  head  of 
Isolation  Hospitals). 

Revisits  to  Cases  under  Isolation.  —  In  many  in- 
stances it  will  be  found  advisable  for  the  inspector  to  revisit 
cases  which  have  been  placed  under  isolation.  Otherwise, 
in  careless  families  or  with  mild  cases,  there  is  a  great  likeli- 
hood that  the  measures  prescribed  will  not  be  entirely  and 
effectively  carried  out.  Even  careful  and  intelligent  people 
frequently  need  additional  advice  and  guidance,  and  may 
get  into  difficulties  if  left  entirely  to  themselves  for  an 
entire  isolation  period.  The  following  practice  may  be 
adopted:  Revisit  each  case  (diphtheria,  scarlet  fever,  etc.) 
within  24  hours  after  the  first  visit;   revisit  again,  if  neces- 


130  A  MANUAL   FOR   HEALTH  OFFICERS 

sary,  after  three  or  four  days;  then  revisit  at  intervals  of  a 
week  or  so.  The  frequency  of  revisits  must  vary  greatly 
according  to  the  circumstances  of  the  case;  the  recom- 
mendation just  given  might  apply  to  an  average  case; 
some  might  require  daily  visits;  others  with  excellent  con- 
ditions no  revisits  at  all.  The  revisits  should  be  at  irregu- 
lar intervals  and  unexpected  times,  and  should,  in  general, 
be  made  more  frequently  in  the  beginning  of  the  period. 

Revisits  may  be  indicated  in  the  inspector's  daily  or 
weekly  reports,  and  may  be  shown  upon  the  spot  map  of 
communicable  disease  as  follows:  on  each  pin  or  tack 
representing  a  case  hang  a  small  tag  (price-tags  are  useful), 
upon  which  dates  of  revisits  may  be  noted  in  abbreviated 
form. 

Application  of  Principles. — The  foregoing  is  not  in- 
tended to  serve  as  a  complete  code  for  isolation  and  quaran- 
tine, but  simply  to  indicate  the  main  considerations,  which 
may  be  covered  by  any  detailed  rules  that  may  be  neces- 
sary. 

In  imposing  restrictions  it  is  the  natural  and  proper 
tendency  of  health  officers  to  be  on  the  safe  side.  It 
should,  however,  be  remembered  that  not  only  the  risk 
avoided,  but  also  the  damage  or  inconvenience  incurred 
must  be  considered;  and  if  the  former  is  not  commen- 
surate with  the  latter  the  restriction  is  unjustified.  While 
the  first  duty  is  to  the  public,  the  individual  should  not  be 
unduly  burdened.  Moreover,  if  restrictions  are  unreason- 
ably severe,  disregard  and  disrespect  are  encouraged. 
Rigid  traditional  rules  should  give  way  to  a  flexible  applica- 
tion of  the  principles  of  sanitary  science,  especially  since 
the  newer  theories  of  infection  have  shown  the  limitations, 
ineptitude,  or  even  the  uselessness  of  the  traditional  cast- 
iron  rules.  The  hardships  and  losses  entailed  by  over- 
rigid  measures  —  i.e.,  through  destruction  of  property, 
restraint  of  persons  from  business  and  school,  nursing,  etc. 
—  should  be  considered. 


COMMUNICABLE  DISEASE  131 

It  scarcely  needs  be  said  that  mild  and  atypical  cases 
should  be  subject  to  the  same  measures  as  the  severe  and 
typical.  It  is  just  such  cases  that  are  most  implicated  in 
spreading  disease.  This  is  a  point  which  the  public  does 
not  understand.  Mild  cases  may  give  rise  to  severe  cases 
and  vice  versa. 

Surveillance  of  *'  Contacts."  —  By  contacts  we  mean 
persons  who  have  been  exposed  to  infection  through  direct 
or  indirect  contact  with  the  patient.  Such  persons  may  or 
may  not  develop  the  disease.  One  of  the  important  duties 
of  the  sanitary  officer  is  to  determine  what  persons  among 
the  associates  of  the  patient  should  be  considered  as  con- 
tacts, and  to  keep  them  under  surveillance.  A  careful 
history  of  the  case  obtained  by  questioning  patient  and 
family  should  indicate  the  chief  contacts.  The  main  point 
in  the  surveillance  is  not  usually  personal  restraint,  but 
periodical  medical  observation.  Thus  children  in  a  family 
where  a  communicable  disease  exists  should  be  watched 
carefully,  and  be  examined,  say  daily  at  first.  This  is  a 
matter  usually  left  to  the  attending  physician,  but  when 
there  is  no  physician,  as  when  the  contact  is  in  another 
family  and  the  family  of  the  suspect  does  not  see  fit  to 
obtain  its  own  physician,  it  may  be  desirable  for  the  board 
of  health  physician  to  oversee  the  person.  It  is  feasible, 
of  course,  to  apply  the  surveillance  only  to  those  cases 
where  there  is  a  considerable  chance  of  the  disease  develop- 
ing. It  is  to  be  maintained  until  the  maximum  incubation 
period  has  elapsed  since  exposure.  Such  a  period  may 
be  ascertained  from  Table  III  at  the  close  of  this 
chapter. 

Terminal  Disinfection.  —  Custom  has  held  that  one  of 
the  chief  safeguards  against  spread  of  infection  is  terminal 
disinfection.  By  this  is  commonly  meant  gaseous  disin- 
fection ("fumigation")  of  supposedly  infected  rooms  and 
articles  after  termination  of  isolation  through  death  or 
recovery  of  patient.     The  practice  is  based  principally  upon 


132  A  MANUAL  FOR  HEALTH  OFFICERS 

the  theories  of  air  and  fomites  infection,  both  of  which,  as 
has  already  been  stated,  are  now  largely  discredited;  and 
in  recent  years  both  theoretical  and  practical  reasons  have 
been  brought  forward  to  show  that  terminal  disinfection  as 
commonly  practiced  is  of  very  much  less  value  than  form- 
erly supposed.^ 

The  argument  against  such  terminal  disinfection  is  based 
chiefly  upon  the  following  facts:  the  low  vitality  of  many 
pathogens  outside  of  the  body;  the  prevalence  of  commu- 
nicable disease  to  the  same  extent  where  such  disinfection 
is  efficient  as  where  it  is  inefficient;  and  the  non-increase  of 
the  disease  in  instances  in  which  such  disinfection  has  been 
abandoned.  In  Providence,  R.  I.,  terminal  disinfection 
has  been  abandoned  after  certain  diseases  except  when 
requested  by  the  family;  thus  the  number  of  disinfec- 
tions has  been  much  reduced  without  any  apparent  ill 
result  (see  Providence  health  report) .^     In  New  York  City 

^  Chapin,  "  Sources  and  Modes  of  Infection."  Also:  Chapin, 
"  The  Value  of  Terminal  Disinfection,"  Jour.  Am.  Pub.  Health  Assn. 
1911,  vol.  I,  no.  I,  p.  32;  Rpt.  Supt.  Health  (C.  V.  Chapin,  M.D.), 
Providence,  R.  I.,  for  1912,  p.  96  flf.;  Arms  and  Whitney,  "  The  Treat- 
ment of  Rooms  after  Diphtheria  and  Scarlet  Fever,"  Am.  Jour.  Pub, 
Health,  1912,  vol.  II,  no.  10,  p.  799. 

*  "  Disinfection  of  rooms  after  diphtheria  and  scarlet  fever  was  dis- 
continued in  1908  in  this  city  of  235,000  inhabitants,  '  living  for  the 
most  part  in  tenements  or  apartments  for  two  to  six  families.'  It  is 
possible,  therefore,  to  make  a  comparison  between  the  percentage  of 
recurrences  (second  cases  in  the  same  family  within  sixty  days)  under 
the  disinfection  system  and  under  the  later  system.  For  the  last  five 
years  of  disinfection  there  was  a  percentage  of  1.48  recurrences  of 
scarlet  fever,  and  in  the  five  following  years,  1.53.  For  diphtheria 
the  figures  are  1.71  per  cent  during  the  first  period  and  1.75  per  cent 
during  the  last.  These  results,  Dr.  Chapin  believes,  show  that  the 
costly  and  time-consuming  practice  of  house  disinfection  has  little  or 
no  influence  on  the  spread  of  these  two  diseases."  {The  Survey,  Nov. 
28,  1914,  p.  214.)  Of  course,  these  results  hold  good  only  for  diphtheria 
and  scarlet  fever.  It  would  be  rash  to  conclude  that  the  same  thing 
would  be  true  with  regard  to  tuberculosis  and  other  diseases  of  which 
the  germs  may  live  longer  in  the  environment. 


COMMUNTCAHLK    DISKASI':  133 

fumigation  has  been  discontinued  after  recovered  cases  of 
diphtheria,  cleansing  measures  being  substituted. 

There  is  also  a  disadvantage  in  the  fact  that  terminal 
disinfection  makes  fomites  infection  from  rooms  and  ob- 
jects appear  much  more  important  than  it  actually  is;  also 
that  people  are  confirmed  in  the  idea  that  a  final  fumigation 
makes  cleansing  unnecessary  and  covers  up  all  carelessness 
which  may  have  existed  in  regard  to  bedside  disinfection. 

There  is,  then,  sufficient  evidence  for  the  oi)ini<)ii  of  the 
Committee  on  Communicable  Diseases  of  the  American 
Public  Health  Association  in  1912^  "that  terminal  room 
disinfection,  as  at  present  practiced  by  the  average  board  of 
health,  has  little  effect  in  controlling  the  spread  of  infection; 
and  that  it  appears,  in  so  far  as  figures  are  available,  that 
the  percentage  of  return  cases  is  practically  the  same  in 
those  communities  where  disinfection  is  compulsory  as  in 
those  where  it  is  not  required." 

So  much  for  the  usual  routine  fumigation.  The  only 
question  now  remaining  is  whether  really  efficient  disinfec- 
tion would  repay,  in  prevention  of  infection,  the  labor  and 
money  put  into  it.  This  question  is  not  yet  conclusively 
answered,  but  there  are  indications  which  would  lead 
one  to  suspect  that  here  too  the  answer  will  be  in  the 
negative. 

At  present  the  practical  health  officer  is  justified  in 
omitting  routine  terminal  disinfection  and  insisting  in- 
stead: first,  upon  careful  bedside  disinfection  during  the 
course  of  the  disease;  and,  second,  at  the  close  of  the  iso- 
lation, upon  appropriate  disinfection  (see  Appendix  A)  or 
destruction  of  any  specific  surfaces  or  articles  which  may 
have  become  contaminated  with  infectious  matter;  the 
whole  to  be  followed  by  sunning  and  airing.  Of  course 
the  second  set  of  precautions  need  be  less  extensive  in 
proportion  as  proper  care  has  been  exercised  during  the 
illness. 

^  Am.  Jour.  Pub.  Health,  1913,  vol.  Ill,  no.  4,  p.  388. 


134  A  MANUAL   FOR   HEALTH  OFFICERS 

Terminal  room  disinfection  may  be  of  some  use  after 
tuberculosis,  the  germs  of  which  are  comparatively  hardy 
and  may  be  thickly  scattered  in  the  apartment  of  a 
careless  consumptive.  But  in  diseases  like  measles  and 
scarlet  fever,  the  virus  of  which  is  apparently  very  short- 
lived, it  can  be  of  very  little,  if  any,  use.  The  supposed 
value  of  such  disinfection  has  been  greatly  exaggerated 
in  the  past,  and  even  now  it  is  not  infrequently  the  futile 
and  wasteful  practice  to  fumigate  whole  houses,  the  only 
result  of  the  process  being  the  conferring  of  a  false  sense  of 
security. 

Under  unusual  circumstances  room  disinfection  is  of 
course  worth  performing  even  if  the  added  precaution  is 
very  slight.  Thus  the  sudden  appearance  of  a  case  of 
smallpox  in  a  smallpox-free  city  might  justify  extreme  pre- 
cautions which  would  not  be  justified  as  routine  measures 
were  the  disease  already  established.  As  Chapin  remarks, 
"A  spark  in  the  dry  grass  should  be  stamped  out  at  any 
cost,  but  it  is  useless  to  waste  time  in  extinguishing  the 
smouldering  flames  left  here  and  there  as  the  line  of  fire 
is  sweeping  across  the  prairie." 

There  is  also  some  justification  for  fumigation  after  the 
removal  of  a  case  to  the  hospital,  or  after  death,  in  the 
height  of  the  disease,  though  even  here  very  much  the  same 
remarks  apply  as  apply  to  terminal  disinfection  strictly 
so-called.  Where  a  thorough  cleansing  of  surfaces  and 
objects  capable  of  being  infected  through  contact  of  dis- 
charges or  hands  or  otherwise,  and  disinfection  of  bedding, 
utensils,  etc.,  can  be  secured,  fumigation  may  well  be 
omitted  in  these  cases  also. 

The  whole  question  of  terminal  room  disinfection  is  at 
present  under  advisement  of  a  special  committee  of  the 
American  Public  Health  Association,  from  which  a  report 
is  soon  to  be  expected. 

Isolation  Hospitals.  —  Difficulties  in  home  isolation  have 
led  to  the  establishment  of  municipal  hospitals  for  com- 


COMMUNICABLK    DISKASK  135 

municablc  disease'  No  community  should  he  without 
such  facihtics.  Expense  need  not  be  a  deterrent,  for  several 
towns  may  unite  in  the  erection  and  maintenance  of  a  joint 
hospital,  or  it  may  be  established  under  county  authority, 
as  has  been  done  in  some  states.  Automobile  ambulance 
transportation  makes  it  possible  to  make  use  of  an  institu- 
tion situated,  if  necessary,  some  distance  away. 

There  are  advantages  in  hospital  facilities  both  as  to 
isolation  and  as  to  treatment.'-^  If  there  is  any  question 
about  home  conditions,  the  case  should  go  to  the  hospital. 
Moreover,  school  children  in  the  family  may  then  go  back 
to  school  so  much  the  sooner,  and  there  is  less  chance  of 
creating  carriers  in  the  family.  Isolation  hospitals  will  not, 
as  Chapin  points  out,  entirely  "stamp  out"  disease,  any 
more  than  home-isolation  will,  but  they  do  have  certain 
positive  advantages. 

Health  authorities  should  be  vested  with  the  power  of 
compulsory  removal  to  the  isolation  hospital,  —  such  power 
to  be  exercised,  however,  only  after  all  means  of  persuasion 
have  been  exhausted  and  upon  proper  authority,  e.g., 
certification  of  the  health  of^cer  (or  health  department 
physician)  and  the  attending  physician  or  isolation  hospital 
physician  that  such  removal  is  necessary.  While  such 
cases  are  infrequent,  the  law  should  be  adequate  and  should, 
when  necessary,  be  firmly  employed. 

Public  opinion  should  be  educated  on  the  advantages  of 
the  isolation  hospital.  Such  an  institution,  built  and 
managed  according  to  the  best  modern  ideas,  should  re- 
move the  popular  dread  of  the  old-fashioned  "pest  house." 
Isolation  hospitals  may,  if  necessary,  be  located  in  populous 

1  Wodehouse,  "  An  Isolation  Hospital  Built  and  Operated  by  a 
City  Department  of  Health,"  Jour.  Am.  Pub.  Health  Assn.,  191 1, 
vol.  I,  no.  10,  677;  Woody,  "  Municipal  Hospitals  for  Contagious  Dis- 
eases," Am.  Jour.  Pub.  Health,  1912,  vol.  H,  no.  9,  p.  726. 

2  Chapin,  Rpt.  Supt.  of  Health,  Providence,  R.  I.,  for  1912,  p.  76; 
Roberts,  "  Quarantine  or  Isolation  in  Diphtheria,"  Am.  Jour.  Pub. 
Health,  191 1,  vol.  I,  no.  5,  p.  353. 


136  A  MANUAL  FOR  HEALTH  OFFICERS 

districts;  there  is  no  danger  to  the  neighborhood  from  a 
propcrh'  conducted  hospital,  popular  prejudice  to  the 
opinion  to  the  contrary  notwithstanding. 

Care  of  Dead  Bodies:  Funeral  Restrictions. — 
Bodies  of  persons  dead  of  communicable  disease  are  tra- 
ditionally sources  of  infection.  This  w£is  perhaps  due  to  a 
false  belief  in  air  infection.  From  what  is  now  known  it  is 
evident  that  a  body  enclosed  in  a  coffin,  especially  when 
embalmed  with  the  powerful  germicides  ordinarily  used  by 
embalmers  (of  which  formalin  is  the  usual  basis),  is  not  a 
source  of  infection.  We  now  know  that  it  is  the  living,  not 
the  dead,  who  spread  disease.  Public  funerals  after  death 
from  certain  communicable  diseases  are  frequently  for- 
bidden, but  the  only  apparent  benefit  lies  in  thus  discourag- 
ing the  association  of  well  persons  with  the  carriers  who  may 
exist  in  the  household. 

We  may  now  take  up  individually  the  diseases  of  the  first 
class,  bearing  in  mind  that  the  preventive  measures  for  all 
are  in  principle  the  same:  isolation,  bedside  disinfection  of 
discharges,  and  withal  prophylactic  cleanliness. 

DIPHTHERIA 

Diphtheria  may  be  described  as  a  specific  local  infection 
of  the  mucous  membranes  of  the  throat  (pharyngeal  diph- 
theria, "membranous  croup")  or  nose  (nasal  diphtheria), 
or  both,  accompanied  by  more  or  less  severe  constitutional 
symptoms.  The  virulence  varies  from  the  mildest  recog- 
nizable cases  up  to  the  most  severe. 

The  causative  organism  is  the  Bacillus  diphtherice  (also 
known  as  the  Klebs-Loeffler  bacillus),  which  may  be 
artificially  cultivated  on  a  special  culture  medium 
("Loefiier  medium")  and  may  be  identified  by  expert 
microscopic  examination  of  the  resulting  culture.  Some 
strains  of  diphtheria  bacilli  are  non-virulent;  in  order  to 
determine  virulence  animal  inoculations  are  necessary. 
The  absurd  popular  idea  that  diphtheria  may  arise  from 


COMMUNICABLE   DISEASE  137 

sewer  gas  and  other  foul  emanations  is  still  frcfjucntly  met 
with.  The  germ  derived  from  a  previous  case  or  carrier  is 
the  invariably  necessary  cause  of  the  disease. 

Antitoxin.  —  A  powerful  remedial  and  prophylactic  agent 
is  fortunately  available  in  diphtheria  antitoxin,  a  serum 
containing  elements  which,  when  injected  into  the  circu- 
lation, neutralize  the  toxin  (poison)  secreted  by  the  diph- 
theria bacillus.  "Antitoxin  is  a  specific  and  sovereign 
remedy.  When  given  in  sufficient  amounts  during  the 
first  24  hours  of  the  disease  it  reduces  the  mortality  to 
practically  nil.  ...  In  order  to  obtain  the  full  life-saving 
benefits  of  diphtheria  antitoxin  it  should  be  given  early  in 
the  disease.  Time  is  the  most  important  factor.  When 
the  damage  to  the  cells  has  been  done,  it  may  be  too  late. 
It  is  not  always  advisable  to  wait  for  bacterial  confir- 
mation." (Rosenau.)  In  severe  cases  especially,  antitoxin 
should  be  administered  early  and  in  one  large  dose;  and 
if  it  be  administered  intravenously  there  is  a  gain  of  some 
hours  in  the  manifestation  of  the  beneficial  results,  which 
are  therefore  greater  than  when  the  same  number  of  units 
are  administered  subcutaneously. 

The  antitoxin  is  an  exceedingly  valuable  agent,  not  only 
for  the  cure  of  the  patient,  but  also  for  the  immunization 
of  those  who  have  been  exposed  to  the  infection  ("con- 
tacts"). Just  what  persons  in  a  family  should  receive 
prophylactic  injections  of  the  antitoxin  is  a  matter  for 
determination  in  the  individual  case,  depending  on  the  de- 
gree of  exposure.  Special  attention  is  to  be  paid  to  chil- 
dren; adults  are  much  less  prone  to  develop  the  disease. 
Where  there  has  been  direct  exposure,  an  immunizing  dose 
of  500  units,  or  preferably  1000  units  (Rosenau)  should 
be  given.  The  protective  effect  gradually  wears  off,  and 
the  dose  should  be  renewed  every  2  or  3  weeks  if  exposure 
has  been  repeated.  "Upon  the  first  appearance  of  sore 
throat,  fever,  or  other  suggestive  symptoms  in  persons  who 
are  exposed  to  diphtheria  a  full  dose  of  3000  to   10,000 


138  A  MANUAL  FOR  HEALTH  OFFICERS 

units  should  be  administered  without  delay. "  (Rosenau.) 
There  should  be  no  hesitation  to  administer  antitoxin 
when  there  is  any  real  danger. 

Contrary  to  what  might  be  expected,  the  ordinary  in- 
jection of  antitoxin  does  not,  according  to  Rosenau,  hasten 
the  disappearance  of  the  bacilli;  and  recovery  does  not 
necessarily  signify  that  the  patient  is  free  from  infection, 
even  though  the  throat  symptoms  have  cleared  up. 

Transmission.  —  The  germs  are  shed  off  in  the  sputum 
and  nasal  discharges  of  the  patient,  though  other  mucous 
membranes  or  abraded  surfaces  may  become  infected  — 
e.g.,  the  conjunctival  or  vaginal  mucous  membrane,  or 
open  wounds  —  in  which  case  the  discharges  from  these 
lesions  are  infectious. 

Contact  infection  (see  page  113)  is  the  chief  mode  of 
transmission,  but  transmission  through  milk  and  other 
food  supplies  readily  takes  place.  The  germs  thrive  in 
milk,  and  many  epidemics  of  milk-borne  diphtheria  are 
on  record. 

Incidence.  —  Diphtheria  is  chiefly  a  disease  of  child- 
hood, the  great  majority  of  cases  occurring  among  infants 
and  children  of  school  age.  It  is  a  disease  of  the  fall  and 
winter  months.  This  seems  to  be  the  effect  of  the  season 
rather  than  of  the  congregation  in  schools.  It  is  a  fact  that 
the  heightened  sensitiveness  of  the  respiratory  passages  at 
this  season,  with  the  additional  strain  thrown  upon  them 
by  poor  ventilation,  tends  to  make  infection  easier.  During 
the  summer  months  there  is  comparatively  little  diphtheria. 

Control.  —  Measures  under  the  following  six  heads  should 
be  adopted  by  health  departments: 

I.  Provide  ready  facilities  for  free  bacteriological  diagno- 
sis by  means  of  diphtheria  cultures.  While  many  cases 
can  be  diagnosed  positively  on  the  clinical  symptoms,  there 
are  also  many  of  an  atypical  or  suspicious  nature  in  which 
the  assistance  of  a  cultural  examination  is  indispensable. 
The  examination  should  be  made  locally  if  a  competent 


COMMUNFCMJI.K    DISKASK  I39 

bacteriologist  is  available,  for  the  transmission  of  cultures 
to  a  distance  impairs  and  delays  tlie  results.  Such  (-xamina- 
tions  are,  however,  frequently  made  for  the  smaller  com- 
munities by  state  health  department  laboratories. 

The  rationale  of  the  cultural  process  is  simple.  A  sterile 
swab  is.  rubbed  by  the  physician  over  the  mucous  mem- 
branes of  both  nose  and  throat,  and  is  then  passed  lightly 
over  the  surface  of  a  special  culture  medium  ("Loefiflcr 
medium").  The  latter  is  then  incubated  at  body  temper- 
ature (37°  C),  and  the  culture  is  examined  microscopically 
after  12  hours  or  so.  The  diphtheria  bacilli,  if  present,  are 
recognized  by  their  microscopical  appearance.  A  practice 
may  be  made  of  receiving  cultures  up  to,  say,  5  p.m.,  for 
examination  and  report  next  morning. 

The  outfit  for  examinations  includes  a  swab  in  a  tube  (two 
swabs  if  separate  examinations  are  to  be  made  for  nose  and 
throat),  both  sterilized,  together  with  a  tube  of  the  sterile 
culture  medium,  both  tubes  being  enclosed  in  a  stiff  en- 
velope, tube  or  box,  with  a  blank  slip  for  filling  in  the  name 
and  address  of  case  and  other  data.  The  physician,  after 
swabbing,  inoculates  the  medium,  and  returns  the  used, 
possibly  infected  swab  to  its  tube.  In  handling  such  out- 
fits after  use,  the  danger  of  possible  infection  must  be 
remembered  and  precautions  taken  accordingly.  Swabs 
alone  should  not  be  received  unless  special  provision  is 
made  for  direct  swab  examinations,  which  are  not  recom- 
mended for  routine  work.  Convenience  may  require  the 
establishment  of  culture  stations  and  collection  incubators 
at  special  points. 

There  are  considerable  practical  dilificulties  in  the  cul- 
tural examination;  diphtheria  germs  originally  present  may 
be  "overgrown"  or  "contaminated"  by  other  forms,  or 
may  be  present  in  very  small  numbers.  Or  it  may  be 
that  they  were  missed  entirely  in  the  process  of  swabbing. 
Even  if  present,  they  may  not  be  typical  in  appearance. 
Considerable  skill  is  necessary  on  the  part  of  the  bacteriol- 


140  A   MANUAL   FOF^   HEALTH   OFFICERS 

ogist  to  render  a  definite  decision,  or  such  a  decision  may 
be  impossible.  The  lesson  to  be  drawn  is  that  even  under 
the  best  conditions  as  to  culture  and  bacteriological  skill, 
there  is  a  considerable  margin  of  uncertainty  involved. 
While  a  positive  cultural  result  may  be  taken  as  assuring  the 
presence  of  diphtheria  bacilli,  a  negative  result  does  not  neces- 
sarily signify  that  the  bacilli  are  absent.  Thus  a  positive 
clinical  diagnosis  should  not  be  reversed  because  of  the 
failure  to  obtain  a  positive  culture.  In  fact,  a  reasonable 
presumption  of  clinical  diphtheria,  though  opposed  to  a 
negative  bacteriological  finding,  should  be  accepted.  It 
is  also  clear  how  two  cultures  taken  at  or  about  the  same 
time  may  turn  out,  one  positive,  the  other  negative;  this 
throws  no  discredit  on  the  method  beyond  the  fact  that  in 
the  latter  case,  for  some  reason,  the  germs  were  missed. 
What  has  been  said  applies  to  single  negative  cultures. 
Since,  therefore,  a  single  negative  culture  indicates  very 
little,  a  negative  decision  should  be  based  only  upon  at 
least  two  consecutive  negative  results.  This  applies  partic- 
ularly in  connection  with  the  release  of  cases  from  quar- 
antine (see  below). 

The  results  of  examinations  should  be  reported  to  physi- 
cians by  telephone,  say  before  lo  a.m.,  under  the  following 
heads : 

1 .  Positive. 

2.  Negative. 

3.  Doubtful,  or  suspicious  (infrequent). 

4.  Contaminated  (rare). 

5.  No  growth  (rare). 

In  the  last  three  cases  another  specimen  should  be  re- 
quested. 

Action  should  at  once  be  taken  in  the  positive  cases,  but 
a  report  in  regular  form  within  the  legal  period  should  be 
required  from  the  physician  in  order  that  the  action  of  the 
department  may  thus  have  his  sanction  in  writing. 

2.    Furnish  a  high-grade  antitoxin  at  cost  (free  to  indigent 


COMMUNICAHI.K    DISF^ASFC  141 

cases)  for  prophylactic  as  well  as  for  curative  purposes. 
Reliable  antitoxin  tested  by  the  U.  S.  Public  Health  Ser- 
vice may  be  obtained  from  commercial  manufacturers  and 
some  state  health  departments.  If  kept  cokl  it  will  kc-ep 
its  strength  practically  unimpaired  for  several  months,  and 
after  its  time  has  expired  may  be  exchanged  for  fresh.  Its 
prophylactic  use  has  already  been  explained.  Physicians 
should  be  notified  of  the  provisions  made  for  distribution, 
and  the  antitoxin  should  be  given  out  to  indigent  cases  on 
the  written  certificate  of  the  attending  physician  that  they 
are  unable  to  pay. 

Attention  is  called  to  the  fact  that  antitoxin  as  ordinarily 
administered  simply  protects  the  individual  without  affect- 
ing the  diphtheria  bacilli  with  which  he  may  be  or  may  be- 
come infected.     (Rosenau.) 

3.  Isolate  known  cases  and,  so  far  as  practicable,  carriers, 
insisting  upon  proper  disinfection  of  the  infectious  dis- 
charges. 

The  isolation  of  known  cases  may  be  carried  out  in  the 
usual  manner,  but  carriers  present  a  very  difficult  problem. 
A  very  considerable  number  of  attendants  on  the  sick  and 
of  persons  in  the  family  of  the  sick,  and  even  some  pro- 
portion of  persons  in  the  general  population  who  have  had 
no  known  association  with  the  disease,  harbor  the  diph- 
theria bacillus  in  the  nose  or  throat,  though  they  remain 
in  good  health.  Graham-Smith  (cited  by  Rosenau)  found 
that  66  per  cent  of  the  members  of  the  family  to  which  the 
diseased  person  belonged  were  infected,  this  proportion 
varying  from  10  to  100  per  cent  accordingly  as  isolation 
precautions  were  or  were  not  taken.  Other  similar  obser- 
vations may  be  cited. ^     Slack,  Arms,  Wade  and  Blanchard  ^ 

^  See  Rosenau,  "  Preventive  Medicine  and  Hygiene,"  1913,  pp. 
146-148;  also  Ledingham  and  Arkwright,  "  The  Carrier  Problem  in 
Infectious  Diseases." 

2  "  Diphtheria  Bacillus  Carriers  in  the  Public  Schools,"  Jour.  Am. 
Med.  Assn.,  March  19,  1910,  vol.  LIV,  pp.  951-954. 


142  A  MANUAL  FOR  HEALTH  OFFICERS 

found  that  at  least  i  per  cent  of  4500  healthy  school  children 
in  Boston  carried  diphtheria  bacilli  without  clinical  symp- 
toms. Moss  ^  found,  among  school  children  and  general 
population  in  Baltimore,  3  to  4  per  cent  of  carriers,  or  20 
carriers  per  known  case,  remarking:  "  that  this  is  far  below 
the  actual  number  is  certain,"  for  only  single  throat  ex- 
aminations were  made.  This  certainly  indicates  that  the 
diphtheria  bacillus  is  widely  distributed.  It  is  fortunate 
that  such  bacilli  have  ordinarily  little  or  no  virulence. 

The  carriers  of  apparently  the  greatest  importance  —  i.e., 
those  who,  while  themselves  immune,  harbor  and  distribute 
virulent  bacilli  —  are  chiefly  to  be  looked  for  within  the 
association  circle  of  the  known  cases.  It  is  through  them 
that  the  disease  spreads,  in  spite  of  isolation,  through  un- 
traced  paths.  Thus  when  25  cases  of  well-recognized  diph- 
theria occurred  in  two  of  the  schools  of  Davenport,  Iowa, 
during  1911-1912,  bacteriological  examination  showed  that 
20  per  cent  of  the  other  children  of  these  schools  were 
diphtheria  carriers.  The  virulence  test  was  positive  in  90 
per  cent  of  the  cases.^ 

A  strictly  logical  plan  would  involve  taking  cultures  from 
members  of  the  family  and  others  within  the  sphere  of 
association  of  the  patient,  and  then  to  isolate  those  who 
show  the  presence  of  the  germs.  This  procedure,  though 
it  has  been  attempted,  would  of  course  involve  many 
difhcultics,  and  public  sentiment,  at  least  at  the  outset, 
would  oppose  it  strongly.  While  sanitary  measures  should 
not  be  carried  beyond  the  point  where  the  restriction  is 
more  burdensome  than  the  evil  which  it  prevents,  never- 
theless the  isolation  —  or  at  least  surveillance  —  of  all 
carriers  is  indicated  on  scientific  principles  as  the  ideal  plan 
and  the  one  which  should  be  approximated  as  nearly  as  pos- 
sible.    Detection  and  isolation  of  carriers  have  proved  their 

^  Trans.  XV  Internal.  Congress  Hyg.  and  Demogr.,  1912,  vol.  IV,  pt. 
I,  p.  156  ff. 

2  Albert,  in  paper  referred  to  below. 


COMMUNICABLE   DTSKASE  143 

value  in  the  control  of  instiltilioiial  cpidcniics  aiiH  slioiild 
be  extended  to  the  general  ixjpulation  s(;  far  as  [possible. 

However,  the  strict  measures  which  might  ai)[)ly  to  a 
diphtheria  outbreak  cannot  be,  applied  to  the  endemic 
diphtheria  which  constantly  exists  in  the  population;  in 
other  words,  we  may  culture  the  persons  in  association  with 
known  cases,  but  we  cannot  well  culture  the  en  lire  jjcjpula- 
tion  to  locate  many  unrecognized  carriers  which  certainly 
exist.  As  in  many  other  sanitary  problems,  where  the  ideal 
is  impracticable  we  must  coi-tipromise  by  doing  what  is 
feasible  and,  within  inevitable  limits,  effective. 

Again,  there  is  no  ready  method  of  distinguishing  between 
the  carriers  of  virulent  and  non-virulent  bacilli.  Conse- 
quently prompt  and  sweeping  action  in  regard  to  carriers 
must  at  the  present  time  include  many  harmless  carriers 
of  non- virulent  bacilli,  who  must  be  restrained  at  least 
until  virulence  tests  of  the  bacilli  can  be  made. 

In  regard  to  outbreaks  in  the  schools,  health  officers 
may  take  a  fairly  definite  course  of  action.  While  the  role 
of  the  schools  in  the  dissemination  of  communicable  dis- 
ease has  undoubtedly  been  exaggerated  in  the  past,  still 
the  school  is  a  place  of  association  of  children  from  various 
homes  and  hence  to  a  certain  degree  a  danger  point.  It  is, 
furthermore,  the  only  place  where  numbers  of  children 
can  well  be  medically  inspected  and  cultured.  Albert,^  in 
a  discussion  of  the  carrier  problem,  stating  that  diph- 
theria carriers  in  the  public  schools  have  been  successfully 
controlled  in  a  number  of  our  larger  cities,  recommends 
the  following  procedure: 

I.  Whenever  there  is  an  outbreak  of  diphtheria  among  the  children  of  a 
certain  school,  the  throat  {and  in  suspicious  cases,  also  the  nasal  cavities) 
of  every  pupil,  teacher  and  other  person  in  such  school  -  should  be  examined 

^  Albert,  "  Diphtheria  Carriers  and  Their  Relationship  to  Medical  In- 
spection of  Schools,"  Am.  Jour.  Pub.  Health,  1912,  vol.  II,  no.  10,  p.  794. 

^  This  procedure  might  perhaps  be  limited  to  the  rooms  or  grades  in 
which  cases  occur.  Thorough  examination  would  require  two  consecu- 
tive cultures  in  each  case.  —  J.  S,  M. 


144  A  MANUAL   FOR  HEALTH  OFFICERS 

both  by  inspection  to  note  the  condition  of  the  throat  and  by  bacteriological 
examination. 

2.  Those  with  a  "sore"  throat  should  be  sent  home  immediately  and 
should  not  be  permitted  to  return  to  school  until  proved  by  bacteriological 
examination  not  {or  no  longer)  to  be  diphtheria  carriers,  or  in  case  the  bacilli 
persist  in  remaining  after  a  thorough  attempt  at  removing  them,  the  patient 
should  remain  isolated  until  it  is  proved  that  the  bacilli  are  not  virulent. 

The  diphtheria  carrier,  rather  than  the  premises,  should  be  quaran- 
tined. The  carrier  should  remain  somewhat  isolated  from  the  other 
members  of  the  family  but  such  other  members  should  be  permitted  to 
go  in  and  out  of  the  house  to  attend  school  or  their  places  of  business. 
It  is  advisable,  however,  to  have  the  house  placarded  to  serve  as  a 
warning  or  notice  to  have  persons,  not  members  of  the  familj%  stay  out. 
The  card  may  be  labeled  as  follows: 

"  Carrier  of  diphtheria  here  —  keep  out." 

It  is  likewise  advisable  to  place  in  the  hands  of  the  family  a  circular 
explaining  what  is  meant  by  a  diphtheria  carrier  and  the  danger  of 
such  and  advising  them  to  call  a  doctor  to  the  house  to  treat  the  nose 
and  throat  in  order  to  remove  the  carrier  condition.  In  case  the  family 
prefers  I  believe  it  to  be  advisable  to  have  the  medical  work  done  by 
the  health  officer,  if  not  a  practicing  physician,  at  public  expense. 

The  following  measures  may  be  employed  to  rid  the  nose  and  throat 
of  diphtheria  bacilli: 

(a)  Local  Application  of  Disinfectants. — The  nasal  cavities  and 
throat  should  be  sprayed  with  a  mild  disinfectant  such  as  a  solution  of 
hydrogen  dioxide  (0.5  per  cent  by  weight  of  absolute  hj-drogen  dioxide 
which  is  the  solution  of  hydrogen  dioxide  of  the  U.  S.  PharmacopcEia 
diluted  with  5  parts  of  water)  or  of  some  mild  alkaline  disinfectant  as 
Carl  Seiler's  solution. 

The  throat  will  permit  of  more  severe  measures  than  the  nose.  A 
solution  of  I  per  cent  by  weight  of  absolute  hydrogen  dioxide  may  be 
used  as  a  gargle  or  the  surface  may  be  swabbed  with  a  5  per  cent  solution 
of  silver  nitrate.  Care  should  be  taken  not  to  have  such  an  excess  of 
the  reagent  on  the  applicator  that  it  will  trickle  to  the  larynx. 

The  local  application  of  such  disinfectants  usually  succeeds  in  re- 
moving the  carrier  condition  in  a  few  days.^     Sometimes,  however,  more 

^  Test  cultures  should  of  course  not  be  taken  for  some  time  after  the 
application  of  disinfectants.  It  should  be  added  that  the  efficacy  of  the 
class  of  treatment  here  described  is  questioned  by  some  authorities. 
Rosenau  states  that  "  careful  attention  to  the  hygiene  and  cleanliness 
of  the  mucous  membranes  may  hasten  their  [the  diphtheria  germs'] 
disappearance,  and  this  is  favored  by  copious  washing  of  the  throat 
and  nose  with  large  volumes  of  physiological  salt  solution.  Antiseptics, 
such  as  silver  nitrate,  applied  locally,  seem  to  be  of  little  service." 
("  Preventive  Medicine  and  Hygiene,"  1913,  p.  148.)  — J.  S.  M. 


COMMUNFCAHI.K    DISKASF-:  145 

drastic  measures  must  I)e  cmploycfl  before  the  ^crms  clisapf)nar.  Know- 
ing that  tlic  crypts  of  tonsils  afforded  a  good  hiding  place  for  the 
bacteria  wc  have  tried  the  disinfection  of  such  by  the  use  of  a  swab 
dipped  in  a  10  per  cent  solution  of  silver  nitrate  anrl  well  introduced 
into  the  crypts.  By  so  doing  we  succcetled  in  getting  rifl  of  the  bac- 
teria in  18  cases  (all  attempted)  which  remained  as  carriers  after  re- 
peated swabbing  of  the  surface.  Squeezing  the  tonsils  anri  forcing  out 
the  exudate  often  existing  in  the  form  of  plugs  from  the  crypts  has 
been  tried  with  some  success  by  Kretschmer,  who  succeeded  in  freeing 
13  patients  from  the  carrier  condition  in  which  the  more  simple  measures 
failed. 

(b)  [Describes  spraying  with  living  cultures  of  staphylococci. 
Omitted  here,  as  this  procedure  does  not  appear  to  be  as  yet  thoroughly 
established.] 

3.  Those  who  have  no  sore  throat  may  remain  in  school  until  [and 
unless]  the  result  of  the  bacteriological  examination  indicates  that  they  are 
diphtheria  carriers.  If  such  is  the  case  they  should  remain  at  home  and  be 
treated  as  mentioned  under  (2). 

It  is  stated  that  such  measures  have  been  effective  in  a 
number  of  instances.  The  writer  just  quoted  states  that 
severe  outbreaks  in  four  cities  in  Iowa  were  so  checked, 
although  similar  outbreaks  which  had  occurred  previously- 
had  continued  for  months.  Instances  may  also  be  cited 
from  Cleveland^  and  elsewhere. 

It  is  certainly  time  that  systematic  detection  of  carriers 
took  the  place  of  the  perfunctory  and  useless  fumigation 
of  school-rooms  which  is  frequently  considered  the  sole 
measure  required  for  the  protection  of  the  school. 

The  problem  of  carriers  demands  the  careful  attention 
of  health  officers,  for  it  is  at  present  the  crux  of  the  control 
of  diphtheria. 

Outbreaks  of  diphtheria  occur  not  infrequently  in  institu- 
tions —  asylums,  hospitals  and  the  like  —  where  it  rapidly 
gains  a  foothold.  The  measures  to  be  recommended  in 
such  instances  are,  according  to  Rosenau:  first,  a  prophy- 
lactic dose  of  1000  units  of  antitoxin  to  all  persons  in  the 
institution;  and,  second,  isolation  of  both  cases  and  car- 

^  Am.  Jour.  Pub.  Health,  1913,  vol.  Ill,  no.  9,  p.  976. 


146  A  MANUAL  FOR   HEALTH   OFFICERS 

tiers.  The  latter  measure  is  the  truly  suppressive,  for  if 
not  properly  carried  out  the  germs  will  persist  longer 
than  the  antitoxin  immunity.  The  latter  must,  however, 
be  renewed,  if  necessary  to  keep  it  up,  every  ten  days  or 
two  weeks.  In  the  detection  of  carriers  all  persons  in  the 
institution,  including  both  inmates  and  administrative 
force,  must  be  examined  culturally,  the  cultures  being 
taken  from  both  nose  and  throat,  and  all  persons  showing 
positive  results  (whether  virulent  bacilli  or  not)  are  to  be 
isolated.  The  usual  prophylactic  measures  are  to  be  em- 
ployed, attention  being  paid  to  towels,  eating  utensils, 
cups,  glasses  and  other  articles  which  may  be  used  in 
common. 

Terminal  disinfection  Is  apparently  of  little  value,  espe- 
cially if  proper  care  has  been  exercised  during  the  course 
of  the  disease. 

4.  Immunize  Contacts.  —  See  under  Antitoxin,  page  137, 

5.  Regulate  the  length  of  isolation  by  the  culture  method.  — 
No  convalescent  or  carrier  should  be  released  until  two 
consecutive  negative  cultures  taken  at  least  24  hours 
apart  have  been  obtained  from  nose  and  throat.^  The 
duration  of  isolation  under  this  rule  will  usually  be  ten 
days  to  three  weeks,  though  some  cases  may  be  kept  con- 
siderably longer.  If  the  germs  persist  an  unusual  length 
of  time  virulence  tests  may  be  made,  and  if  the  culture 
proves  non-virulent  the  case  may  be  released. 

6.  As  regards  school-children:^  on  account  of  the  possi- 
bility of  carriers,  children  (other  than  the  patient)  in  in- 
fected families  should  be  excluded  from  school  during  the 
quarantine,  and  should  not  be  re-admitted  until  one  nega- 
tive or  non- virulent  culture  from  nose  and  throat  has  been 
obtained   from   each   child   in   the   family.     Such   cultures 

1  Slack,  "  A  Resume  of  Diphtheria  Examinations  made  in  the  Boston 
Board  of  Health  Bacteriological  Laboratory  in  1909,"  Jour.  Am.  Pub. 
Health  Assn.,  191 1,  vol.  \,  no.  11,  p.  819. 

*  Cf.  remarks  on  school  outbreaks,  above,  p.  143  ff. 


COMMUNICABLE  DISEASE  147 

should  not  be  taken  until  48  hcnirs  after  tlu;  termination  of 
isolation,  so  tliat:  any  bacilli  present  may  have  time  to 
develop.  It  would  be  advisable,  where  this  plan  is  adopter!, 
to  keep  up  the  placard  and  maintain  the  quarantine  on  the 
family  until  all  the  cultures  have  provefl  negative. 

As  for  children  in  non-infected  families  in  the  same 
house,  if  there  has  been  much  associatifjn  such  cliildrcn 
should  be  excluded  from  school  like  children  in  tlie  infected 
family.  If,  however,  there  has  been  little  association  and 
good  quarantine  exists,  such  children  may  be  permitted 
to  attend  if  they  show  negative  (or  non-virulent)  cultures 
taken  48  hours  after  institution  of  the  quarantine. 

If  the  case  goes  to  the  hospital,  or  the  well  children  of 
the  family  go  promptly  to  live  away  from  home,  they  may 
return  to  school  if  their  cultures  taken  48  hours  afterwards 
are  negative.  Children  in  the  other  families  in  the  house, 
if  there  has  been  association  with  the  patient,  may  be 
treated  likewise. 

The  practice  in  regard  to  these  matters  varies,  and  no 
absolute  rules  can  be  laid  down.  The  above,  however, 
represent  good  practice  at  the  present  time  and  serve  to 
illustrate  the  principles  involved. 

SCARLET   FEVER 

Scarlet  fever  (scarlatina)  is  an  acute  febrile  infection 
characterized  by  sore  throat  and  a  diffuse  eruption  which 
appears  during  the  first  day  or  two  of  the  fever.  i\fter 
several  days  the  inflammation  in  the  skin,  which  gives  the 
disease  its  name,  gives  way  to  a  peeling  of  the  superficial 
layer  of  the  skin  —  known  as  desquamation.  The  disease 
varies  in  virulence;  most  of  the  cases  now  seen  are  mild, 
some  scarcely  recognizable  except  by  the  desquamation; 
and  desquamating  but  previously  unrecognized  cases  are 
not  infrequently  found,  e.g.,  in  medical  school-inspection. 
Popularly  it  is  often  thought  that  "scarlatina"  is  a  mild 
infection  distinct  from  scarlet  fever;    this,  of  course,  is  in- 


148  A  MANUAL  FOR  HEALTH   OFFICERS 

correct,  the  two  terms  being  interchangeable.  Even  in 
mild  cases  serious  aftereffects  upon  kidneys  and  other 
organs  are  to  be  guarded  against  through  care  in  convales- 
cence. 

The  cause  of  scarlet  fever  is  as  yet  unknown.  Strep- 
tococci are  constantly  found  in  the  throats  of  scarlet  fever 
cases,  but  the  etiologic  connection  has  not  been  established. 

With  scarlet  fever,  as  compared  with  diphtheria,  we  are 
at  a  disadvantage,  for  we  do  not  know  the  causative  organ- 
ism, are  unable  to  trace  the  paths  of  transmission,  and  have 
no  specific  antitoxin  as  a  preventive  and  curative  agent. 

Transmission.  —  The  chief  source  of  infection  in  scarlet 
fever,  so  far  as  known,  is  the  secretions  of  the  mucous 
membranes  of  the  nose,  throat  and  respiratory  tract.  The 
infection  enters  the  body  by  the  same  routes.  Accord- 
ing to  the  best  opinion  to-day  the  desquamation  (scales) 
plays  little  or  no  part  in  infection,  especially  in  the  latter 
stages.  Hence  desquamating  patients  may  safely  be  re- 
leased provided  sufficient  time  has  elapsed  and  the  condi- 
tion of  the  mucous  membranes  is  normal.  On  the  other 
hand,  patients  who  have  finished  desquamating  may  still 
spread  infection  through  abnormal  discharges  from  throat, 
respiratory  passages,  nose,  or  ear,  or  other  sequelae.  Such 
facts  are  established  by  a  study  of  the  "return  cases"  oc- 
curring in  a  family  after  the  return  of  patients  discharged 
from  the  hospital. 

Since  the  cause  of  scarlet  fever  is  unknown  there  is  no 
way  of  determining  just  when  each  patient  ceases  to  be 
infective. 

Scarlet  fever  is  about  as  communicable  as  diphtheria, 
i.e.,  less  so  than  measles  and  smallpox. 

Carriers  and  mild  and  unrecognized  cases  are  unques- 
tionably frequent,  and  play  a  great  part  in  disseminating 
the  disease. 

Scarlet  fever  is  transmitted  chiefly  by  contact  in  just 
the  same  way,  so  far  as  known,  as  diphtheria.     Foods  may 


COMMUNICABLE   DISEASE  149 

also  convey  the  infection;  many  milk-h(;rnc  epidemics  are 
on  record. 

Incidence.  —  Scarlet  fever,  like  (li|)litlieria,  is  a  child- 
hood disease,  the  great  majority  of  cases  occurring  under 
fifteen  years  of  age.  Its  seasonal  incidence  resembles  that 
of  diphtheria,  the  majority  of  cases  occurring  during  the 
winter  months.  During  the  summer  season  it  usually 
drops  to  a  very  low  point. 

Control.  —  Known  cases  should  be  isolated  and  dis- 
charges from  nose  and  mouth  disinfected,  and  efforts  should 
be  made  to  detect  mild  and  atypical  cases  in  the  zone  of 
association  of  the  patient.  Medical  school  inspection  helps 
in  locating  such  cases.  Parents  should  be  educated  to  be 
watchful  for  early  symptoms  in  their  children. 

Streptococcus  vaccines  have  been  used  with  apparently 
favorable  results  in  immunizing  persons  against  scarlet 
fever,  but  have  not  yet  been  tried  out  in  this  country.^ 

Terminal  disinfection  is  apparently  of  little  or  no  value, 
especially  if  proper  bedside  disinfection  has  been  carried  out. 

The  period  of  isolation  varies  with  different  authorities. 
Very  long  periods  are  excessive  and  are  a  burden  on  the 
family,  without  apparent  commensurate  benefit  to  the 
community.  No  patient  should,  however,  be  released  if 
inflammation  of  the  throat  or  discharge  from  nose,  ear  or 
abscess  persists,  for  the  secretions  in  such  instances  may 
remain  long  infective.  Cases  may  be  released  when 
abnormal  discharges  have  ceased  and  the  patient  appears 
normal  {even  if  desquamation  is  incomplete) ;  a  minimum 
period  of  four  iveeks  should,  however,  be  maintained.  This 
practice  has  been  proved  safe  by  experience  in  towns  and 
hospitals.^ 

^  Rosenau,  "  Preventive  Medicine  and  Hygiene,"  1913,  p.  164. 

*  Rpt.  Committee  on  Communicable  Diseases,  Am.  Pub.  Health 
Assn.,  Atn.  Jour.  Pub.  Health,  1913,  vol.  Ill,  no.  4,  p.  387. 

Cf.  the  following:  —  "  In  England,  where  more  work  of  this  kind 
seems  to  have  been  done,  it  has  been  found  that,  by  discharging  patients 
when  the  throat  and  nose  appear  normal  without  regard  to  desquama- 


150  A  MANUAL  FOR  HEALTH  OFFICERS 

As  to  school-children:  since  there  may  be  carriers  in  the 
zone  of  association  of  the  case,  it  may  be  safest  to  exclude 
all  children  in  the  house  (including  those  in  non-infected 
families)  during  the  period  of  quarantine.  If,  however,  the 
quarantine  is  good,  it  is  proper  to  permit  children  in  the 
non-infected  families  to  return  to  school  one  week  after 
the  quarantine  has  been  instituted.  (This  allows  time  for 
development  of  the  disease  if  they  have  been  infected;  if 
they  have  previously  had  the  disease  they  may  return  at 
once.)  Medical  inspection  of  schools  is  an  additional  safe- 
guard in  such  cases.  Children  in  the  infected  family 
should  be  excluded  until  the  expiration  of  one  week  after 
the  termination  of  isolation. 

If,  however,  the  case  goes  to  the  isolation  hospital  or 
the  well  children  leave  home,  they  may,  if  free  from  symp- 
toms, return  to  school  one  week  later. 

MEASLES 

Measles  (morbilli)  is  an  acute  febrile  disease  character- 
ized by  skin  eruption  and  inflammation  of  the  mucous 
membranes  of  the  eyes,  nose  and  respiratory  passages.  In 
itself  it  is  usually  not  severe,  but  its  complications  and 
aftereffects  (e.g.,  especially  pneumonia)  are  to  be  feared. 
The  fatality  is  greatest  in  infants  and  young  children. 

tion,  the  average  stay  in  hospital  was  reduced  from  45  to  29 -[-days 
without  any  increase  in  the  percentage  of  return  cases.  .  .  .  Obser- 
vations in  this  country  seem  to  show  that  patients  with  a  nasal  dis- 
charge but  free  from  desquamation  invariably  cause  return  cases  soon 
after  release,  while  patients  who  are  desquamating  but  free  from  nasal 
discharge  do  not  so  cause  return  cases."  (Previous  report  of  above 
Committee,  Am.  Jour.  Pub.  Health,  1912,  vol.  II,  no.  2,  p.  122.)  Some- 
times the  discharged  patient  develops  a  recurrence  in  the  form  of  a 
"  cold  "  and  this  is  followed  by  a  return  case.  The  Committee  recom- 
mends further  study  of  the  subject  of  return  cases,  as  to  whether  the 
discharged  patient  had  desquamation  or  nasal  discharge  or  both,  and 
as  to  whether  the  patient  developed  a  "  cold  "  shortly  before  the  onset 
of  the  return  case. 


COMMUNfCAHIJ-:    DISEASE  151 

The  importance  of  measles  as  a  cause  of  death  is  shown 
in  Chart  2,  where  it  ranks  with  scarlet  fever.'  This  fact 
is  not  generally  recognized.  Many  measles  deaths  are 
inaccurately  assigned  hy  physicians  to  terminal  conditions 
of  pneumonia,  etc.,  and  are  so  classified. 

The  cause  is  unknown. 

Transmission.  —  Measles  is  one  of  the  most  highly 
communicable  diseases  known,  ranking  with  smallpox. 
This  has  led  many  observers  to  believe  that  the  virus  is 
air-borne.  This  may  be  so  in  some  instances,  but  contact 
(including  droplets)  infection  from  the  secretions  of  the 
nose,  throat,  and  respiratory  passages  is  probably  respon- 
sible for  the  great  majority  of  cases. 

Contrary  to  former  belief,  modern  evidence  indicates  a 
strong  probability,  if  not  altogether  a  certainty,  that  the 
desquamation  is  not  a  medium  of  infection. 

Measles  is  readily  transmissible  by  contact  and  man  is 
susceptible  to  even  minute  amounts  of  the  infection,  but 
the  virus  dies  out  quickly  in  the  environment.  Rosenau 
states  that  after  two  weeks  following  termination  of  isola- 
tion there  is  practically  no  danger  of  contracting  the  disease 
from  the  room  in  which  the  patient  has  been  treated,  even 
without  disinfection.  Fomites  infection  would  therefore  be 
rare. 

The  incubation  period  is  long  (9  to  11  days,  possibly 
14),  and  the  disease  is  contagious  for  several  days  before 
definite  symptoms;  it  may  also  possibly  remain  contagious 
in  convalescence. - 

Incidence.  —  Measles  is  a  disease  of  infancy  and  child- 
hood; over  half  the  fatal  cases  occur  in  infants  under  two 
years,  and  over  80  per  cent  under  five  years.  When  it 
occurs  in  later  adolescence  and  adulthood,  the  fatality  is 
very  much  less. 

^  A  detailed  statistical  study  of  measles  has  been  made  by  Crum, 
Am.  Jour.  Pub.  Health,  1914,  vol.  IV,  no.  4,  p.  2S9. 
*  See,  however,  note  on  next  page. 


152  A   MANUAL   FOR   HEALTH   OFFICERS 

Control.  —  There  are  two  great  obstacles  to  the  control 
of  measles:  its  extreme  contagiousness  and  the  fact  that  it 
is  contagious  for  some  time  before  it  can  be  positively 
recognized.^  The  prodromal  symptoms  are  those  of  an 
ordinary  coryza  or  cold  in  the  head,  —  symptoms  so  com- 
mon among  children  as  ordinarily  to  give  rise  to  no  suspi- 
cion. Most  of  the  harm  is  done  before  the  diagnosis  is  made, 
and  in  many  cases  no  physician  is  called  at  all.  There 
may  also  be  carriers  and  unrecognized  cases,  but  probably 
less  frequently  than  in  scarlet  fever,  diphtheria  and  typhoid 
fever. 

For  the  reasons  above  set  forth,  the  ordinary  measures 
of  isolation,  etc.,  can  accomplish  but  little.  Neverthe- 
less it  is  worth  while  to  do  what  is  feasible  to  prevent 
infection  from  known  cases.  Even  if  but  a  compara- 
tively small  number  of  cases  and  deaths  are  saved,  the 
measures  are  justified.  Health  authorities  should  there- 
fore: 

I.  Require  reporting  of  cases,  and  quarantine  them  in 
a  modified  manner  for  15  days  from  onset  and  until  all 
symptoms  have  disappeared. ^  The  mildness  of  convales- 
cence and  popular  indifference  toward  the  disease  make  a 
strict  isolation  in  most  cases  impracticable ;  but  the  patient 
should  be  required  to  remain  on  the  premises,  and  a  placard 
should  be  used  to  warn  children  from  entering.  Other 
children  in  the  family  are  almost  certain  to  take  the  dis- 
ease unless  strictly  separated.  Terminal  disinfection  is  of 
practically  no  value. 

Children  in  the  infected  family  should  be  excluded  from 

1  The  difficulties  are  well  illustrated  in  an  outbreak  which  occurred 
in  Chicago    (Young,  Am.  Jour.   Pub.    Health,   1912,  vol.   II,  no.   10, 

p.  791)- 

*  Experiments  (Anderson  and  Goldberger,  U.  S.  Pub.  Health  Ser- 
vice) on  monkeys  show  an  apparent  period  of  infectivity  of  only  three 
days  —  24  hours  before  and  48  hours  after  the  appearance  of  the  erup- 
tion. The  minimum  15-day  quarantine,  however,  tends  to  insure  proper 
convalescence,  and  errs,  if  at  all,  on  the  safe  side. 


COMMUNICABLE   DISEASE  153 

school  for  15  (lays'  unless  they  can  show  medical  certifi- 
cates that  they  have  had  measles.  It  is  difficult  to  keep 
measles  from  spreading  to  other  children  in  the  family. 
Such  children,  if  they  have  not  already  had  the  disease 
and  have  not  been  exposed,  may  be  sent  away  from  home, 
but  the  possibility  of  still  further  spreading  the  disease  in 
case  they  may  have  been  exposed  must  be  considered. 
Children  in  other  families  in  the  house  need  not  be  excluded 
unless  they  have  been  exposed. 

2.  Endeavor  to  obtain  early  recognition  and  medical 
treatment  of  cases.  Parents  should  learn  to  treat  all 
"colds"  in  children  as  suspicious,  to  keep  such  children 
separate  from  others,  and  to  guard  against  contact  infection 
until  the  nature  of  the  "cold"  is  ascertained.  Infection, 
by  the  suspect,  of  towels,  handerchiefs,  toys,  eating  uten- 
sils and  other  articles  used  in  common  among  children 
should  be  avoided.  Such  home  prophylaxis  is  also  of  much 
value  as  a  protection  against  the  other  communicable 
diseases  which  frequently  start  with  symptoms  of  a  fever- 
ish cold  or  a  sore  throat.  Publicity  on  such  subjects  is 
desirable.  When  parents  take  such  matters  more  seriously 
a  corresponding  advance  in  prevention  will  result. 

3.  Call  attention  of  physicians  and  of  parents  of  cases 
to  the  need  of  care  in  convalescence  in  order  to  avoid  serious 
aftereffects.  In  this  way  the  fatality  rate  may  be  reduced. 
The  same  precaution  applies  to  whooping  cough,  light  cases 
of  scarlet  fever  and  other  mild  diseases  from  which  the  chief 
danger  is  to  be  apprehended  in  the  incidental  effects  upon 
heart,  lungs,  kindeys  and  other  vital  organs. 

^  Since  the  incubation  period  is  long,  it  has  been  suggested  that  such 
children  be  allowed  to  continue  at  school  for  8  or  10  days  after  exposure, 
then  be  excluded  for  a  week  to  ten  days,  after  which  those  who  do  not 
develop  the  disease  may  be  allowed  to  return.  This  plan,  according  to 
Rosenau,  is  followed  in  certain  districts  in  England.  It  assumes,  how- 
ever, that  the  time  and  period  of  exposure  are  definitely  known  for  each 
child,  which  is  not  always  the  case;  and  in  any  case  safe  leeway  should 
be  allowed. 


154  A  MANUAL  FOR  HEALTH  OFFICERS 

GERMAN   MEASLES 

German  measles  (rubeola,  rubella,  rotheln)  resembles 
measles  in  symptoms  and  transmission,  but  is  a  distinct 
disease  and  of  less  importance.  It  is  chiefly  of  interest  in 
relation  to  the  schools.  It  may  be  made  subject  to  similar 
measures,  with  a  minimum  quarantine  of  lo  days. 

WHOOPING   COUGH 

Whooping  cough  (pertussis)  is  an  infection  caused  by  the 
bacillus  discovered  by  Bordet  and  Gengou.  It  is  of  much 
greater  importance  as  a  cause  of  mortality  among  infants 
and  young  children  than  is  popularly  supposed;  the  mor- 
tality ranks  with  that  of  scarlet  fever  (Chart  II,  page  76), 
and  is  due  largely  to  the  pulmonary  complications,  chiefly 
pneumonia.  Doubtless  a  considerable  number  of  the 
deaths  are  put  down  to  the  latter  instead  of  to  the  primary 
cause. 

Transmission.  —  The  virus  exists  chiefly  in  the  expec- 
toration, but  all  secretions  from  nose  and  mouth  are  to  be 
guarded  against.  Whooping  cough  is  communicable  from 
the  earliest  symptoms,  during  convalescence,  and  even  after 
the  subsidence  of  the  characteristic  cough,  being  most 
infectious  during  the  early  stages.  Transmission  is  chiefly 
by  contact.  Domestic  animals  (dogs  and  cats)  may  become 
infected  and  transmit  infection.  Mild,  unrecognized  cases 
play  a  part  in  its  extension. 

Incidence.  —  The  great  majority  (95  per  cent)  of  the 
fatal  cases  occur  under  five  years  of  age,  and  over  half  in 
infants  under  one  year. 

Control.  —  Most  of  the  remarks  made  under  the  head 
of  measles  apply  in  substance  here.  The  obstacles  to 
control  are:  that  the  disease  is  communicable  before  it  is 
recognized;  that  the  infective  convalescent  period  is  long, 
lasting  possibly  eight  weeks;  that  the  mildness  of  conva- 
lescence makes  quarantine  measures  irksome  and  difficult 


COMMUNTCAFU,!'!    DISKASE  1 55 

to  enforce;  and  that  parents  regard  the  rhsease  merely  as 
an  inevitable  and  harmless  incident  of  chilrlhoorl.  As  in 
measles,  however,  health  authorities  should  take  what 
precautions  are  feasible,  even  if  these  are  by  no  means 
ideal.     Such  are: 

1.  To  require  reporting  of  cases. 

2.  To  institute  a  modified  quarantine,  as  in  measles. 
During  the  long  period  of  convalescence  the  patient  should 
be  allowed  a  certain  degree  of  freedom,  provided  he  does 
not  come  in  contact  with  other  children  or  handle  articles 
which  may  be  handled  or  eaten  by  them.  Fresh  air  is  a 
helpful  curative  agent,  and  the  patient  may  be  allowed 
airings  under  adult  care.  It  has  been  proposed  that  such 
patients  be  allowed  freedom  with  the  requirement  that  they 
wear  some  warning  mark,  such  as  a  green  or  yellow  arm- 
band. Infection  of  infants  and  old  persons  should  be  espe- 
cially avoided  on  account  of  the  possible  serious  conse- 
quences. Either  such  persons  or  the  patient  may  to 
advantage  be  sent  away  from  home.  The  restrictions 
should  be  kept  up  until  all  symptoms  have  disappeared  — 
preferably  several  days  longer;  some  authorities  recom- 
mend a  period  of  even  eight  weeks. 

Terminal  disinfection  is  of  no  practical  value. 
Well  children  in  the  family  need  not  be  excluded  from 
school  unless  they  have  a  suspicious  cough. 

3.  To  inform  parents  as  to  the  seriousness  of  the  disease 
and  the  importance  of  early  prophylaxis  in  case  of  sus- 
picious symptoms  in  children  (see  measles).  Many  cases 
are  not  considered  serious  enough  to  call  a  doctor. 

A  vaccine  (pertussin)  may  be  used  for  both  curative  and 
prophylactic  purposes,  but  its  use  is  not  yet  established.^ 

LOBAR  PNEUMONIA 

Pneumonia,   an   infection  by   the  Pneumococcus,   rivals 
and   sometimes   exceeds    tuberculosis   as   the   chief   of   all 
1  Am.  Jour.  Pub.  Health,  1913,  vol.  Ill,  no.  8,  p.  839. 


156  A  MANUAL   FOR   HEALTH  OFFICERS 

causes  of  death.  Like  tuberculosis  it  may  be  regarded  as 
an  infectious  and  communicable  disease  of  which  the  germs 
arc  extensively  distributed  but  which  depends  for  its  propa- 
gation upon  lowered  vital  resistance  of  individuals  rather 
than  upon  facilities  for  infection.  Epidemics  of  pneumonia 
have,  however,  been  noted,  and  in  a  sense  it  may  be  re- 
garded as  a  constantly  pandemic  disease  to  which  we  have 
become  accustomed. 

Transmission.  —  The  pneumococcus  may  frequently  be 
found  in  the  mouths  of  healthy  persons,  who  are  not  affected 
by  it  until  some  depression  of  vital  resistance  permits  in- 
vasion by  the  germ.  Even  robust  persons  may  succumb 
if  their  vital  resistance  is  greatly  depressed.  On  the  other 
hand,  each  case  should  be  regarded  as  a  focus  of  fresh  in- 
fection which  may  be  communicated  by  the  various  ways 
of  contact  infection.  It  is  possible  that  in  many  of  these 
cases  the  germs  are  of  a  heightened  virulence.  It  is  also 
possible  that  there  are  unrecognized  carriers  of  especially 
virulent  pneumococci.  Lack  of  proper  ventilation,  dusty 
atmospheres,  exposure,  intemperance  and  neglected  colds 
are  among  the  predisposing  factors. 

Incidence.  —  The  mortality  from  pneumonia  is  dis- 
tributed over  all  ages.  Nearly  one-fifth  of  the  fatal  cases 
occur  under  two  years  of  age,  nearly  one-third  over  sixty 
and  the  remainder  over  the  prime  of  life.  It  is  one  of  the 
chief  factors  in  infant  mortality,  and,  since  it  may  be  almost 
entirely  prevented  by  proper  infant  hygiene,  we  must  to 
that  extent  at  least  place  pneumonia  among  the  diseases 
controllable  through  public  hygiene. 

Control.  —  The  principles  of  prevention  are :  first  and 
chiefly,  keeping  up  the  vital  resistance  of  individuals;  and, 
second,  limiting  so  far  as  practicable  the  spread  of  the  pneu- 
mococcus. The  first  of  these  lies  largely  within  the  control 
of  the  individual  and  is  to  that  extent  a  matter  of  personal 
hygiene.  The  health  authorities  may,  however,  combat 
pneumonia  in  the  following  ways: 


communi(;ai5I-I';  diskask  157 

1.  By  improving  housing  and  factory  conditions,  especially 
as  regards  ventilation. 

2.  By  popular  education  on  personal  hygiene  —  e.g.,  the 
value  of  fresh  air,  avoidance  of  "contact"  infection,  etc. 

3.  By  infant  hygiene  work. 

4.  By  advising  prophylaxis  in  the  individual  case.  Pre- 
cautions similar  to  those  for  tuberculosis  should  be  taken  — 
i.e.,  proper  care  of  the  sputum.  Such  measures  arc  in  the 
hands  of  the  physician,  nurse  and  family. 

CEREBROSPINAL   FEVER 

This  disease,  which  may  also  be  called  "epidemic  cere- 
brospinal meningitis, "  is  an  infection  by  the  Meningococcus, 
an  organism  which  attacks  the  meninges  (membranes)  of 
the  brain  and  spinal  cord.  It  is  only  one  of  the  infections 
known  by  the  loose  general  term  "meningitis,"  and  should 
not  be  confused  with  others.  In  order  to  avoid  confusion 
the  above  two  exact  terms  and  no  others  should  be  used 
(preferably  "cerebrospinal  fever ").^ 

Transmission.  —  Cerebrospinal  fever  occurs  sporadically 
(single  cases)  and  epidemically  (groups  of  cases).  It 
occurs,  like  other  diseases  in  which  the  infection  probably 
takes  place  through  the  respiratory  system,  especially  in 
the  fall  and  winter  months. 

It  is  supposed  that  the  infective  organism,  the  meningo- 
coccus, enters  the  system  through  the  mucous  membrane 
of  the  nasopharynx,  and  that  the  infection  is  spread  through 
"contact"  transference  of  the  discharges  and  secretions 
from  mouth  and  nose. 

Incidence.  —  Children  and  young  adults  are  most 
susceptible. 

Control.  —  Cerebrospinal  fever  offers  great  resistance  to 
control  on  account  of  the  large  number  of  its  carriers.  One 
authority  (Fliigge)  estimates  that  healthy  carriers  of  the 

'  See  discussion  of  undesirable  terms  in  the  International  List  of 
Causes  of  Death. 


15S  A  MANUAL  FOR  HEALTH  OFFICERS 

disease  arc  ten  limes  as  numerous  as  recognized  cases.  It 
is  believed  that  these  carriers  are  the  principal  agents  in 
the  spread  of  the  disease,  and  that  the  germ  passes  rather 
directly  from  one  person  to  another,  developing  only  in  a 
comparatively  small  number  of  susceptible  persons.  On 
the  other  hand,  when  the  disease  is  prevalent  it  may  be- 
come very  severe;  thus  in  New  York  in  1904-1905  there 
,  were  6755  reported  cases  and  3455  deaths. 

As  to  control,^  the  large  number  of  carriers  greatly 
lessens  the  value  of  isolation  of  known  cases,  while  the 
bacteriological  detection  of  all  carriers  and  their  control 
is,  under  ordinary  circumstances,  impracticable.  Neverthe- 
less, until  more  exact  knowledge  of  the  disease  is  obtained, 
health  authorities  should  require  reporting  of  cases  and 
suspected  cases,  isolation  until  bacteriological  disappear- 
ance of  the  meningococcus,  and  disinfection  of  the  sputum 
and  nose  discharges.  By  these  measures  some  secondary 
cases  and  fresh  carriers  may  be  prevented,  especially  if 
prompt  steps  are  taken  with  the  first  cases  reported. 

Chronic  carriers  should  be  kept  under  restrictive  con- 
trol, should  be  given  careful  instructions  for  avoiding 
spreading  the  disease  to  others  through  their  secretions, 
and  should  receive  vaccine  treatment  (see  below). 

Health  authorities  should  provide  facilities  for  bacterio- 
logical diagnosis  (by  examination  of  the  spinal  fluid)  of 
cases  and  carriers.  They  should  also  be  prepared  to 
supply  antimeningitis  serum  (a  curative  though  not  a  pre- 
ventive). Immunization  maybe  effected  through  inocula- 
tion with  a  vaccine  of  killed  meningococci.  Chronic  carri- 
ers should  also  be  treated  with  the  vaccine. 

TUBERCULOSIS 

Tuberculosis  is  the  chief  disease  with  which  health  author- 
ities have  to  deal.     In  191 1,  in  the  Registration  Area  of 

^  Cf.  Von  Ezdorf,  "  Epidemic  Cerebrospinal  Meningitis:  Informa- 
tion Relative  to  Prevention  of  Spread  of  the  Disease  and  Management 
of  Cases,"   U.  S.  Pub.  Health  Rpts.,  May  9,  1913. 


communicahi.p:  diskase  159 

the  United  States,  it  caused  11.2  per  cent  of  all  rieaths. 
The  disease  has  its  roots  deep  in  a  complex  of  social  and 
sanitary  conditions  which  makes  it  also  the  most  refractory 
of  public  health  problems. 

The  tubercle  bacillus  exists  in  several  different  types, 
the  most  important  of  which  is  the  human  type.  The 
bovine  type  may  also  infect  man  through  the  medium  of 
milk.  The  bacillus  may  invade  any  part  of  the  body: 
hence  the  various  forms  of  tuberculosis  —  tuberculosis  of 
the  lungs,  tuberculous  meningitis,  abdominal  tuberculosis, 
generalized  tuberculosis,  etc.  Tuberculosis  of  the  lungs 
(synonyms:  pulmonary  tuberculosis,  consumption,  phthisis) 
is  the  commonest  form;  it  caused  83  per  cent  of  all  deaths 
from  tuberculosis  in  the  U.  S.  Registration  Area  in  191 1. 

The  question  as  to  the  severity  of  the  disease  depends  not 
only  upon  the  virulence  of  the  organism  in  any  particular 
case,  but  also  very  largely  upon  the  vital  resistance  of  the 
person.  The  infection  is  very  widely  spread,  and  many 
persons  undoubtedly  harbor  the  bacillus  without  perceptible 
bad  effects  and  practically  without  being  sources  of  infec- 
tion to  others.  This  fact,  which  is  demonstrated  by  post- 
mortem findings  of  old  healed  lesions,  is  expressed  in  the 
saying  current  among  German  bacteriologists,  "Everyone 
is  a  little  tuberculous."  The  question  of  combating  tuber- 
culosis is  therefore  largely  —  though  by  no  means  entirely 
—  a  matter  of  keeping  up  the  vital  resistance  of  individuals, 
both  the  well  and  the  openly  tuberculous. 

In  short,  the  development  of  the  infection  depends  upon 
two  contrary  factors:  the  amount  of  i^ifection  (i.e.,  the  num- 
ber of  bacilli,  which  perhaps  also  vary  in  virulence),  and  the 
vital  resistance  opposed  to  it  by  the  system  of  the  person. 
The  balance  between  these  two  factors  determines  how  far 
the  pathological  processes  shall  go.  Hence  there  are  all 
degrees  of  infection,  from  that  which  is  unrecognizable  in 
its  mildness  to  the  most  rapid  "galloping  consumptien." 
Hence,  too,  there  may  be  accelerations,  retardations,  arrests 


l6o  A  MANUAL   FOR  HEALTH  OFFICERS 

and  recoveries  in  the  course  of  the  disease.  Thus,  while 
tuberculosis  is  communicable,  its  development  depends 
largely  upon  the  state  in  which  it  finds  the  individual. 

Transmission.  —  The  bacillus  is  shed  off,  in  pulmonary 
tuberculosis,  in  the  sputum  raised  by  coughing.  It  is  most 
often  spread  by  the  various  kinds  of  contact  infection 
(page  113).  Transmission  through  infected  food  (and  per- 
haps water)  is  also  possible.  It  is  believed  that  "house 
infection"  may  take  place,  —  i.e.,  well  persons  may  appar- 
ently contract  the  disease  from  apartments  previously 
infected  by  a  consumptive;  but  this  probably  occurs  less 
frequently  than  is  commonly  supposed,  for  in  many  such 
cases  the  possibility  of  "direct  infection  from  a  case  is  not 
excluded.  While  the  r61e  of  dust  in  conveying  tubercle 
bacilli  is  still  in  dispute,  it  would  appear  that  this  mode 
of  infection,  relatively  to  more  direct  modes,  has  been  ex- 
aggerated. Nevertheless  promiscuous  spitting  should  be 
forbidden,  and  dust  should  be  suppressed  if  for  no  other 
reason  than  that  sharp,  irritating  dust  particles  render  the 
mucous  membrane  of  the  respiratory  passages  susceptible 
to  the  infection.  It  is  because  of  the  latter  reason  that 
certain  dusty  trades  strongly  predispose  to  tuberculosis. 

Infection  may  take  place  either  by  inhalation  or  by  in- 
gestion, —  i.e.,  either  through  the  respiratory  system  or 
through  the  alimentary  system.  The  question  which  of 
these  modes  is  the  more  common  is  still  in  controversy. 
In  the  case  of  contact  infection  it  is  evident  that  the  in- 
fection might  take  place  in  either  manner. 

Tuberculosis  may  also  be  contracted  through  ingestion 
of  milk  and  milk  products  from  tuberculous  cows.  In 
this  case  it  is  the  bovine  type  of  bacillus  which  is  trans- 
mitted. The  danger  from  this  source  is  largely  restricted  to 
children.  English  and  German  commissions  and  certain 
American  authorities  (notably  Park  and  Krumwiede  of  the 
New  York  City  Department  of  Health)  have  studied  the 
matter  extensively;   as  the  result  of  such  studies  it  may  be 


COMMUNICABLE   DISEASE  l6l 

stated  that  "perhaps  7  per  cent  of  the  tuberculosis  in  man 
is  of  bovine  origin."  ^  The  great  bulk  of  this  consists  of 
generahzed,  abdominal  and  glandular  tuberculosis  among 
children,  scarcely  any  being  of  the  pulmonary  form.  Such 
findings  arc  the  Ijasis  for  legislation  ref|uiring  the  tuber- 
culin testing  of  dairy  herds  and  the  pasteurization  of  milk 
(see  Chapter  III). 

Incidence.  —  Tuberculosis  falls  with  especial  severity 
upon  persons  in  the  prime  of  life,  about  one-half  of  the 
deaths  occurring  among  persons  20  to  40  years  of  age. 

In  considering  tuberculosis  death  statistics  it  must  be 
remembered  that  some  such  deaths  may  be  returned  as 
due  to  other  causes.  There  may  be  mistaken  diagnosis,  or 
the  physician  in  doubt  may,  on  account  of  popular  preju- 
dice against  tuberculosis,  sign  the  certificate  with  some  other 
cause. 

A  striking  feature  of  the  tuberculosis  problem  is  that  it 
is  intimately  connected  with  the  vital  resistance  of  individ- 
uals as  affected  by  many  conditions.  Thus  it  goes  hand 
in  hand  with  poverty,  poor  nutrition,  overwork,  worry  and 
intemperance  of  all  kinds,  —  in  short,  with  any  condition 
which  impairs  health.  Syphilis,  typhoid  fever  and  other 
diseases  predispose  to  it.^  Exposure,  followed  by  pneu- 
monia or  even  a  neglected  cold,  may  be  the  introduction 
to  incipient  tuberculosis.  Overcrowding  is  a  favoring 
condition,  by  reason,  not  only  of  the  greater  chances  of 
infection,  but  also  of  the  physically  depressing  conditions 
accompanying  it.  It  is  observed  that  a  large  proportion  of 
the  cases  and  deaths  occur  in  a  relatively  small  proportion 
of  the  houses  in  a  community.  Poor  housing,  with  deficient 
light  and  ventilation,  is  a  contributory  factor.  Of  special 
importance  are  the  conditions  in  factories:  poor  ventila- 
tion, irritating  dusts  and  vapors,  promiscuous  spitting, 
excessive  length  or  severity  of  labor,  and  the  like.     \Miile 

^  Rosenau,  "Preventive  Medicine  and  Hygiene,"  1913,  p.  124. 
^  See  p.  78,  regarding  typhoid  fever  followed  by  tuberculosis. 


l62  A  MANUAL   FOR  HEALTH  OFFICERS 

certain  of  these  conditions  can  be  dealt  with  by  the  health 
authorities,  many  are  in  the  control  of  the  public  itself 
and  can  only  be  attacked  by  educational  efforts.  No  other 
disease  is  so  firmly  entrenched  in  fundamental  social  con- 
ditions. 

Depression  of  vital  resistance  caused  by  any  of  such 
conditions  may  permit  development  of  the  latent  infection 
which  apparently  exists  in  almost  all  persons.^ 

City  life,  with  its  congestion  and  attendant  insanitary 
conditions  favors  tuberculosis;^  but  the  disease  prevails 
also  in  rural  districts  to  a  greater  extent  than  commonly 
supposed,  being  favored  there  by  under-nutrition,  overwork, 
lack  of  ventilation  in  farm  houses,  etc. 

The  various  races  show  different  degrees  of  incidence, 
owing  doubtless  to  their  modes  of  life  as  well  as  to  differ- 
ences in  racial  susceptibility.  Thus  the  negroes  show  an 
especially  high  death  rate  (405  as  compared  with  126  for 
whites,  under  condensed  title  "tuberculosis  of  lungs," 
Registration  Area,  191 1).  Males  show  a  markedly  higher 
rate  than  females,  doubtless  because  of  more  unfavorable 
conditions  of  labor  and  more  numerous  occasions  of  infec- 
tion. 

CONTROL 

As  already  implied,  prophylaxis  consists  (i)  in  avoiding 
infection,  and  (2)  in  maintaining  or  increasing  vital  resist- 
ance. 

Avoidance  of  infection  is  only  relative,  for  the  tubercle 
bacillus  is  so  widespread  that  few  persons  or  none  can  avoid 
a  certain  minimum  amount  of  infection.  Nevertheless,  this 
amount  should  be  so  far  as  possible  reduced  and  all  occasions 
of  gross  and  obvious  infection,  as  from  direct  exposure  to 
sputum  from  careless  consumptives,  should  be  absolutely 
avoided. 

'  See  note,  p.  163. 

2  Brewer,  "  City  Life  in  Relation  to  Tuberculosis,"  Am.  Jour.  Pub. 
Health,  1913,  vol.  Ill,  no.  9,  p.  163. 


COMMUNICABLE   DISEASE  163 

Vital  resistance  may  Ix;  increased  bolh  ihrow,:,]}  per- 
sonal iiygiene  and  through  vSanitation  oi  the  environment, 
as  outlined  below. 

Tuberculosis  is  not  hereditary  (as  was  formerly  thought), 
and  is  seldom  acquired  congenitally.  The  fact  that  it 
tends  to  run  in  families  may  be  explained  by  inherited 
predisposition,  or  by  increased  chances  of  infection  from 
other  members  of  the  family,  or  both.  Even  with  such  a 
predisposition,  however,  if  good  conditions  are  maintained 
the  individual  may  ward  off  the  disease. 

There  is  no  specific  serum  or  other  remedy  for  tuberculosis. 
The  natural  cure  consists  in  building  up  the  vital  resistance 
of  the  patient  to  throw  off  the  infection,  through  a  well- 
regulated  regimen  of  good  food,  rest,  fresh  air,  cheerful 
surroundings,  etc.,  —  a  logical  extension  of  the  methods  of 
proper  living  which  play  the  chief  part  in  prevention. 
Treatments  with  tuberculin  (an  emulsion  of  killed  bacilli) 
are  of  use  only  when  carefully  administered  in  conjunction 
with  the  natural  cure.  Tuberculin  is,  however,  of  some 
value  in  diagnosis  (in  the  von  Pirquet  cutaneous  reaction, 
or  "skin  test,"  etc.).^ 

From  what  has  been  said  it  is  plain  that  administrative 
measures  must  be  of  two  kinds: 

(i)  Restriction  of  the  spread  of  the  tubercle  bacillus. 

(2)  Promotion  of  the  vital  resistance  of  individuals. 

The  first  of  these  requires  cognizance  of  recognized  cases 
of  tuberculosis  and  measures  to  prevent  the  spreading  of 
the  germ  by  such  cases.  Although  many  unrecognized 
cases  will  escape  such  supervision,  and  some  recognized 
cases  will  disregard  the  rules  imposed,  nevertheless  these 
measures  will   greatly  diminish   the  chances  of  infection. 

^  Tuberculin  diagnosis  has  a  striking  result  in  showing  that  almost 
all  persons  beyond  infancy  have  at  least  a  latent  tuberculosis  infection. 
Thus  recent  authorities  (Hamman  and  Wolman,  "  Tuberculin  in  Diag- 
nosis and  Treatment,"  1912)  state  that  while  the  test  is  of  considerable 
value  under  one  year  of  age,  it  is  of  less  value  from  one  to  two  years, 
of  little  value  in  childhood,  and  none  in  adulthood. 


164  A  MANUAL  FOR  HEALTH  OFFICERS 

Experience  shows  that  the  normal  human  system  is  capable 
of  resisting  small  doses  of  infection  when  it  would  succumb 
to  a  heavier  dose,  and  it  is  just  these  heavier  doses  which 
supervision  over  the  germ-shedding  patient  prevents. 
This  first  class  of  measures  also  includes  prevention  of  the 
spread  of  the  bovine  tubercle  bacillus  through  milk. 

The  second  class  of  measures  —  promotion  of  vital  re- 
sistance —  is  one  which  is  largely  in  the  hands  of  individ- 
uals themselves,  for  many  of  the  conditions  predisposing 
to  tuberculosis  are  capable  of  control  only  through  proper 
habits  on  the  part  of  the  person.  But  at  the  same  time 
there  are  environmental  conditions,  in  factories,  tenements, 
schools,  etc.,  which  can  and  should  be  remedied  only  by  the 
public  authorities. 

Bearing  in  mind  the  above  objects  we  may  pass  on  to  a 
consideration  of  the  means  for  attaining  them. 

I.  Registration  of  Cases.  —  It  is  essential  that  the  local 
health  department  have  a  complete  record  of  all  known 
cases  of  tuberculosis  in  any  of  its  manifestations.  By  far 
the  greatest  number  of  these  will,  as  already  indicated,  be 
of  pulmonary  tuberculosis  (consumption).  Reports  should 
be  made  by  physicians  on  a  special  blank.  Tuberculosis 
records  should  be  kept  separate  from  those  of  the  other 
communicable  diseases.  Most  laws  prescribe  that  tuber- 
culosis records  be  kept,  except  as  administration  requires 
otherwise,  private,  —  a  concession  to  the  false  reproach 
traditionally  attached  to  the  disease.  A  serial  book  record 
in  which  reports  are  briefly  entered  and  numbered  in 
the  order  of  their  receipt,  and  a  card  catalog  of  histories 
arranged  alphabetically  by  name  of  patient,  constitute 
(as  for  other  communicable  diseases)  a  convenient  re- 
cording system.  In  the  catalog  it  will  be  found  best  to 
subdivide  the  index  into  "current  cases,  nurse's  visits 
required,"  "current  cases,  nurse's  visits  unnecessary," 
"school  children"  (special  classes),  "cases  gone  to  hospital 
or  sanatorium"  (each  institution  separately),  "left  town," 


COMMUNTCAIUJC    DTSKASE  165 

"lost  trace  of,"  "suspected  cases,"  "diefl,"  f)r  Lhc  like; 
and  shift  the  cards  as  occasion  may  rcfjuirc  from  one  class 
to  another. 

It  is  desirable  also  to  keep  an  index  and  spot  map  of 
houses  in  which  cases  exist;  in  this  way  foci  of  infection 
are  seen  at  a  glance. 

On  account  of  the  difficulties  of  keeping  track  of  tuber- 
culosis cases  the  following  classes  of  reports  should  be  re- 
quired, the  responsibility  in  each  instance  being  clearly 
defined. 

As  to  neiv  cases: 

(a)  Reports  from  physicians; 

(b)  Reports  from  institutions  and  organizations  under 
whose  notice  cases  may  come ; 

(c)  Reports  from  keepers  and  proprietors  of  lodging- 
houses  and  hotels. 

As  to  cases  already  known,  reports  of  removal: 

(a)  Report  from  physician  when  a  case  moves  away  or 
passes  from  his  professional  care ;  ^ 

(&)  Similar  reports  from  institutions  and  organiza- 
tions ; 

(c)  Report  from  owner,  lessee,  tenant,  or  occupant  of 

^  The  only  way  in  which  this  provision  can  be  eflfectively  carried 
out  is  by  checking  up  the  location  of  all  cases  by  periodic  inquiry  of  the 
physician,  at  least  for  those  cases  which  are  not  visited  frequently  by 
the  nurse.  Note  the  following  resolution  of  the  New  York  City  Depart- 
ment of  Health,  19 10: 

"  It  is  hereby  ordered  that  every  physician  having  a  case  of  pulmo- 
nary tuberculosis  under  his  care  be  required  to  notify  the  Department  of 
Health  once  a  month,  on  cards  furnished  for  that  purpose,  if  patient 
still  resides  at  original  address  given;  if  not,  of  any  change  of  address 
of  such  patient,  in  order  that  the  premises  vacated  may  be  properly 
disinfected  by  the  Department. 

"  And  further  ordered  that  every  physician  be  required  to  notify 
the  Department  of  Health  in  the  same  manner  whenever  a  case  of  pul- 
monary tuberculosis  passes  from  his  professional  care,  or  fails  to  ob- 
serve the  necessary  sanitary  precautions,  in  order  that  the  Department 
may  assume  surveillance  of  such  a  case." 


1 66  A   MANUAL   FOR   HEALTH  OFFICERS 

any  dwelling  or  apartment,  stating  the  removal  of  any 
tuberculosis  patient  therefrom.^ 

There  is  an  unfortunate  tendency  with  some  physicians 
to  slight  the  reporting  of  tuberculosis,  owing  perhaps  to 
the  impression  that  no  special  action  is  taken  by  the  health 
authorities.  Unfortunately,  too,  that  impression  is  some- 
times correct.  But  where  active  measures  are  taken  and 
the  importance  of  reports  is  impressed  on  physicians,  their 
cooperation  is  readily  enlisted.  Prompt  reports  (within 
48  hours  or  less)  should  be  required.  Physicians  should 
be  kept  well  supplied  with  the  necessary  blank  forms. 
Where  reporting  is  good  a  considerable  number  of  duplicate 
cases  will  be  reported  —  i.e.,  the  same  case  will  be  reported 
two  or  three  or  more  times  by  different  physicians,  hospitals 
or  dispensaries.  Patients  tend  to  go  from  one  physician 
to  another,  hence  such  duplicate  reports  should  invariably 
be  required.  The  data  so  obtained  should  be  entered  in  the 
file  on  account  of  the  confirmatory  history  and  the  record 
of  the  movements  of  the  patient  which  they  furnish.  As 
to  hospitals,  dispensaries  and  other  institutions,  it  is  best 
that  the  physician  making  the  diagnosis  of  tuberculosis 
should  be  specifically  required  to  make  report  over  his  own 
signature,  thus  relieving  the  institution  authorities  of 
responsibility.  With  cases  admitted  without  diagnosis  — 
which  is  left  to  the  interne  —  such  a  provision  is  especially 
appropriate.  In  any  case  it  is  strictly  the  physician,  not 
the  institution,  which  makes  or  confirms  diagnosis. 

It  sometimes  happens  that  a  case  is  reported  only  a  few 
hours  before  death.  Such  cases  should  be  investigated  in 
order  to  determine  whether  a  diagnosis  had  not  previously 
been  made  by  the  physician  and  the  report  neglected.     In 

^  To  carry  out  this  provision,  the  person  responsible  for  each  dwell- 
ing or  apartment  should  be  notified  of  the  existence  of  the  case,  so 
that  such  person  may  be  held  strictly  accountable  for  notifying  the 
health  department  when  the  patient  moves  (plan  recently  adopted  in 
Montclair,  N.  J.). 


COMMUNICAIilJ';    DISICASK  167 

some  cases  it  may  be  found  that  the  physician  in  question 
was  called  in  only  a  few  hours  before  death;  under  such 
circumstances  an  effort  should  be  made  to  determine 
whether  diagnosis  had  not  previously  been  made  by  some 
other  physician  who  had  failed  to  report.  It  is  by  such 
following-up  that  the  most  important  instances  of  failure 
to  report  are  discovered. 

All  deaths  from  tuberculosis  should  be  checked  over  to 
ascertain  if  the  cases  heivc  been  reported,  and  when  reports 
have  not  been  filed  the  matter  should  be  taken  up  with 
the  physician  who  signed  the  death  certificate.  It  has  been 
estimated  that  for  every  death  from  tuberculosis  there  are 
about  three  living  dangerously  infective  cases;  but  there 
should  be  a  greater  number  of  cases  on  record,  for  some 
cases  reported  do  not  show  a  positive  sputum  and  cannot 
therefore  be  classed  as  openly  infective.^  These  latter 
cases  may,  however,  be  partly  balanced  by  dangerous  cases 
not  under  medical  care.  Of  course  the  total  actual  number 
of  cases  in  a  community,  including  persons  in  some  material 
degree  infected  but  not  dangerous  and  not  under  medical 
care,  is  considerably  greater  than  reported  numbers. 
Deficiencies  in  reporting  should  be  dealt  with  as  strictly 
as  in  any  other  communicable  disease.  Health  officers 
should  endeavor  to  win  the  full  cooperation  of  the  medical 
profession  by  indicating  the  high  importance  of  this  class 
of  reports;  but  persistence  in  failure  to  obey  the  law  after 
warning  has  been  given  should  be  dealt  with  by  prosecution. 
In  a  small  city  known  to  the  writer  the  annual  number  of 
reported  cases  of  tuberculosis  was  increased,  through  the 
activity  of  the  health  officer,  from  41  to  116  in  two  consecu- 
tive years  (the  number  of  deaths  showing  no  increase). 
Where  the  number  of  reported  cases  is  less  than  the  num- 
ber of  deaths  in  the  same  year,  deficienc^^  in  reporting  is 
to  be  suspected. 

1  Bishop,   "  Tuberculosis,  A  Public  Health  Problem,"   Am.   Jour. 
Pub.  Health,  1913,  vol.  Ill,  no,  4,  p.  329. 


l68  A  MANUAL   FOR  HEALTH  OFFICERS 

Bacteriological  Diagnosis.  —  Official  facilities  for 
bacteriological  diagnosis  should  be  provided.  While  many 
cases  are  readily  diagnosed  clinically  and  should  be  reported 
without  awaiting  bacteriological  examination,  the  latter 
is  indispensable  in  at  all  doubtful  cases.  It  consists  in 
staining  and  microscopic  examination  of  the  sputum  (or 
other  discharge)  for  the  presence  of  the  tubercle  bacillus. 
If  the  bacillus  is  present  in  considerable  numbers,  in  the 
specimen,  it  may  readily  be  positively  recognized  by  the 
regular  technique.  A  single  negative  result  should  not, 
however,  be  given  too  great  weight,  for  it  is  possible  (as 
was  remarked  in  connection  with  diphtheria)  that  the 
bacilli  may  be  few  and  escape  observation,  or  that  the  sample 
is  not  a  representative  one.  Therefore  two  or  more  nega- 
tive results  must  be  obtained  before  the  absence  of  the 
tubercle  bacillus  can  be  asserted  with  reasonable  certainty. 
Suspected  persons  should  be  examined  at  intervals  of  several 
weeks.  In  collecting  specimens  for  examination  for  pul- 
monary tuberculosis,  care  should  be  taken  that  the  true 
sputum  —  i.e.,  the  material  coughed  up  from  the  lungs 
and  lower  respiratory  passages  —  is  obtained.  In  special 
cases,  when  it  is  difficult  to  obtain  a  specimen  through 
coughing,  laryngeal  swabbing  may  be  resorted  to  and  a 
smear  made  for  examination.  Regular  outfits  for  collect- 
ing specimens,  together  with  a  blank  form  for  name  of 
patient  and  other  data,  should  be  provided.  Many  health 
departments  not  having  bacteriological  facilities  for  this 
purpose  arrange  that  physicians  transmit  samples  to  the 
state  laboratory  for  examination. 

2.  Home  Supervision.  —  Once  a  case  has  been  reported 
to  the  health  authorities,  it  becomes  their  duty  to  take 
steps  to  prevent  further  infection  from  the  patient.  Some 
laws  make  the  physician  also  responsible  to  a  certain  ex- 
tent for  instruction  of  the  patient  in  preventive  measures; 
but,  on  the  whole,  the  responsibility  rests  upon  the  health 
authorities  themselves.     Since  the  dangerous  cases  are  the 


COMMUNTCAin.E    DTSKASF':  169 

"open  cases"  of  pulmonary  tuberculosis  (other  ffjrms  not 
usually  being  actively  infectious),  the  precuutif;nary  meas- 
ures to  be  taken  relate  very  largely  to  the  proper  care  of 
the  infectious  sputum.  The  guarding  against  contact  with 
the  patient  of  other  members  of  the  family,  and  the  for- 
bidding of  the  patient  to  engage  in  preparation  of  food  for 
public  distribution,  constitute  a  second  class  of  precautions. 
At  the  present  time,  and  doubtless  for  a  long  time  to  come, 
the  majority  of  patients  —  especially  those  in  the  less  ad- 
vanced stages  —  will  have  to  be  left  in  their  natural  envi- 
ronment —  the  home;  and  measures  will  have  to  be  largely 
concentrated  there.  And  since  strict  isolation  is  nearly 
always  impracticable  as  well  as  unnecessary  (patients 
requiring  stringent  control  being  sent  to  a  hospital  or 
sanatorium),  such  measures  will  have  to  consist  chiefiy  in 
supervision  through  instruction. 

The  Tuberculosis  Nurse.— Under  such  circumstances 
the  health  authorities  work  largely  through  the  public 
health  nurse,  whose  functions  have  already  been  roughly 
described  in  the  first  part  of  this  book.  The  tuberculosis 
nurse  performs  duties  which  in  this  case  go  far  beyond 
those  of  the  ordinary  sanitary  inspector.  She  instructs 
the  patient  as  to  the  nature  of  his  disease,  especially 
with  reference  to  the  danger  of  its  spread  to  others.  She 
sees,  above  all,  that  scrupulous  care  is  observed  in  the  dis- 
posal of  sputum,  —  the  rule  simply  being  that  all  sputum 
and  discharges  from  mouth  and  nose  of  the  patient  are 
destroyed.  For  this  purpose  it  is  convenient  to  use  pieces 
of  cloth  which  may  be  burned,  or,  better,  the  sputum  cups 
or  receptacles  specially  manufactured  for  that  purpose. 
(The  health  department  should  provide  such  receptacles 
liberally  and  free  of  cost  to  patients;  they  may  be  pur- 
chased wholesale  at  low  prices.)  The  precautions  with 
regard  to  sputum  apply  to  the  patient  when  abroad  in  the 
streets  as  well  as  at  home,  a  pocket  sputum  cup  being  used. 
The  patient  must  further  be  instructed  in  the  cleanliness 


170  A  MANUAL  FOR  HEALTH  OFFICERS 

to  be  exercised  in  keeping  the  hands  free  from  infection, 
avoiding  contact  infection  in  the  family,  and  avoiding  con- 
taminating objects  which  may  be  used  by  other  persons. 

While  there  is  practically  no  danger  in  living  with  a  care- 
ful consumptive,  there  is  a  great  deal  of  danger  with  a 
careless  one.  The  danger  in  personal  association  is  always 
very  great  unless  strict  precautions  are  taken.  Working 
in  the  same  room  or  eating  at  the  same  table  demand  such 
precautions;  sleeping  in  the  same  bed  occasions  a  serious 
risk.  A  tuberculous  member  of  the  family  preparing  food 
for  other  members  will  infect  the  food  unless  extraordinary 
precautions  be  taken,  and  such  precautions  cannot  com- 
monly be  expected.  The  board  of  health  of  Montclair, 
N.  J.,  has  recently  passed  a  resolution  to  the  effect  that 
children  under  sixteen  years  of  age  will  not  be  allowed  to 
live  in  a  house  where  there  is  a  case  of  tuberculosis  unless 
extreme  precautions  are  taken  to  prevent  the  spread  of 
infection. 

Tuberculosis  patients  who  are  active  sources  of  infection 
should  be  forbidden  to  engage  in  the  preparation,  for 
public  distribution,  of  kinds  of  food  liable  to  infection; 
they  should  not  act  as  cooks,  bakers,  confectioners,  and  the 
like,  whose  products  pass  directly  to  the  consumer  and  are 
consumed  without  further  cooking. 

The  nurse  has  a  further  duty  to  perform  in  giving  the 
patient  general  advice,  subject  to  the  orders  of  the  attend- 
ing physician,  as  to  the  course  of  life  he  should  adopt  for 
his  own  benefit.  She  may  recommend  a  certain  diet, 
help  arrange  for  outdoor  sleeping  facilities,  and  the  like. 
Indirectly,  whatever  aids  in  the  cure  of  the  case  tends  to 
the  prevention  of  other  cases.  She  should  not,  however, 
perform  actual  nursing  service  except  of  a  minor  sort; 
where  such  is  needed  the  district  visiting  nurse  should  be 
called  in.  The  function  of  the  tuberculosis  nurse  is  to 
gain  the  confidence  of  the  patient,  instruct  and  counsel, 
and  see  that  her  instructions  are  carried  out. 


COMMUNfCAHM',    hISKASK  171 

The  tuberculosis  nurse  may  also  perform  a  fxrtain  atnount 
of  incidental  sanitary  inspection,  and  can  discover  incip- 
ient, untreated,  or  unreported  cases. 

In  the  selection  of  cases  for  visiting,  a  certain  discre- 
tion, which  depends  partly  ujion  the  opinion  of  the  attend- 
ing physician  and  partly  upon  the  circumstances  of  the  case 
as  judged  by  the  heallh  authorities,  must  be  observed. 
Thus  there  will  be  a  certain  number  of  cases,  under  the 
care  of  private  physicians  —  some  perhaps  in  well-to-do 
families  —  in  which  satisfactory  precautions  are  observed 
and  which  it  is  a  waste  of  time  as  well  as  an  intrusion  to 
visit.  The  cases  requiring  most  attention  are  those  marked 
by  ignorance,  carelessness,  or  wilful  disregard  of  sanitary 
precautions.  There  is  a  certain  proportion  of  such  cases 
in  every  community.  Some  such  patients  are  even  va- 
grants, having  no  fixed  abode  and  moving  uncertainly  about 
from  day  to  day,  being  walking  and  (by  most  persons) 
unrecognized  distributors  of  infection.  These  patients 
escape  from  the  surveillance  of  the  health  authorities  only 
to  reappear  from  time  to  time  at  new  points.  They  have 
the  restlessness  characteristic  of  some  stages  of  the  disease 
combined  wath  lack  of  any  feeling  of  responsibility.  They 
have  no  physicians,  no  fixed  associations,  and  constitute  a 
sore  problem  of  the  health  ofiicer  and  tuberculosis  nurse. 
Of  such  cases  and  others  of  the  more  dangerous  class  we 
shall  speak  later  under  the  head  of  institutional  care. 

The  following,  in  some  detail,  are  the  duties  of  the  tuber- 
culosis nurse} 

Each  nurse  should  be  on  duty  at  least  six  hours  daily,  exclusive  of 
one  hour  for  lunch  (Saturdays,  three  hours  daily).  The  health  depart- 
ment badge  is  worn  when  on  duty. 

A  series  of  forms,  more  or  less  according  to  local  needs,  are  used  for 
taking  histories  (for  filing  as  already  explained),  for  authorizing  free 
sputum  cups,  for  recommending  cleansing,  renovations,  etc. 

1  Adapted  (as  also  the  ensuing  section)  from  Monograph  no.  i  of  the 
N.  Y.  City  Dept.  of  Health,  Feb.,  1912.  Details  may  of  course  be 
altered,  added,  or  omitted  to  suit  local  conditions. 


172  A  MANUAL  FOR  HEALTH  OFFICERS 

Each  morning  a  list  is  made  of  cases,  new  and  old,  to  be  visited,  and 
these  are  cleared  up  if  possible  during  the  day. 

The  nurse  cooperates  with  the  health  department  physician  or  the 
health  officer  in  investigating  and  recommending  forcible  removal  of 
patients.  In  all  such  cases  persuasion  is  first  used  in  order,  if  possible, 
to  obtain  the  patient's  consent. 

Suspected  cases  and  complaints  (coming  usually  from  charitable 
organizations)  may  be  tactfully  investigated  by  the  nurse,  who  tries  to 
persuade  the  person  to  go  to  the  clinic  or  at  least  she  endeavors  to  ob- 
tain a  specimen  of  sputum.  If  the  result  of  the  latter  is  negative  and 
the  person  declines  to  go  to  the  clinic,  the  health  department  physician 
may  be  requested  to  make  an  examination. 
When  on  duty  the  nurse  carries  with  her: 

Clinical  thermometer; 

Watch  with  second  hand; 

Fountain  pen; 

History  cards  (for  new  cases  found  in  district); 

Cards  for  referring  patients  to  clinic; 

Circulars  of  information  for  consumptives  and  their  families,  and 
sweeping  and  dusting  leaflets,  in  the  language  spoken  in  her 
district ; 

Sputum  bags  and  paper  napkins; 

Placards; 

Fumigation  cards; 

Sputum  bottles,  for  obtaining  specimens  of  sputum. 
The  first  duty  of  the  tuberculosis  nurse  is  to  exercise  the  necessary 
sanitary  supervision  over  the  cases  of  pulmonary  tuberculosis  living  in 
her  district.  Almost  the  first  question  asked,  when  making  a  visit  on 
a  new  case,  is  whether  the  patient  is  under  the  continued  care  of  a  pri- 
vate physician;  if  so,  his  name  and  address  are  obtained.  In  tracing 
cases  on  first  visit  or,  if  unable  to  obtain  admission,  when  making  a 
revisit,  no  messages  are  left  with  neighbors.  The  reason  for  the  nurse's 
visit  (i.e.,  that  there  is  a  consumptive  on  the  premises)  is  only  to  be 
given  to  the  family.  The  nurse  furnishes  the  department  of  health 
with  prompt,  accurate  and  sufficiently  frequent  reports  as  to  where  the 
patient  is,  his  general  condition,  whether  the  necessary  precautions  are 
being  observed  (sputum,  etc.),  if  he  is  receiving  medical  care  and  where, 
the  nature  and  condition  of  the  house  and  rooms  in  which  he  lives,  the 
number  in  the  family,  etc.  She  calls  attention  to  any  faulty  conditions 
and  recommends  steps  to  be  taken  for  their  betterment.  The  case  is 
kept  under  sanitary  supervision  and  visited  every  few  days  until  faulty 
conditions  are  corrected  or  recommendations  carried  out.  Certain 
cases  under  a  private  physician's  care  may  be  visited  from  time  to  time 


COMMIJNICAI'.I.K    l)l,Si;/\SK  I73 

merely  to  ascertain  if  tiic  paliciil  is  slill  on  llic,  jjremiscs  .iikI  iiiiflcr  llir; 
same  |)hysician's  care. 

Circulars  of  instructions  in  the  language  of  I  lie  palicnl  arc  ^ivcn  lo 
the  patient  or  the  family. 

In  addition  —  and  more  important  —  the  nurse  personally  inslruci3 
the  patient  and  his  family  as  to  the  precautions  to  he  observed.  All 
patients  not  under  the  care  of  a  private  physician  are  given  a  card  to 
the  tuberculosis  clinic  and  urged  to  attend.  All  cases  arc  revisited  at 
least  once  in  two  months  and  advanced  or  refractory  cases  as  much 
oftener  as  may  be  necessary. 

Any  other  suspicious  cases  of  tuberculosis  among  the  family  and 
neighbors  are  traced  and  reported.  Should  the  patient  be  a  child 
attending  school,  the  nurse  reports  whether  or  not  he  or  she  should  be 
excluded  from  school.  The  welfare  of  any  sickly  or  anaemic  children 
is  looked  after  and  they  are  protected  against  infection  as  far  as  possible. 
If  necessary  their  admission  to  a  fresh-air  school,  a  day  camp,  or  a  pre- 
ventorium is  recommended  on  daily  report.  The  nurse  reports  where 
treatment  of  rooms  is  required,  and  any  necessary  orders  are  issued  by 
the  office.  Dirty  and  infected  goods  may  be  ordered  disinfected  without 
waiting  for  the  termination  of  the  case  by  death  or  removal. 

If  the  patient  is  at  work,  the  nurse  reports  as  to  whether  the  work  is 
harmful  to  him  or  her,  or  a  menace  to  fellow  workmen,  or  if  he  or  she 
is  likely  to  spread  infection  to  the  public  (bakers,  handlers  of  food- 
stuffs, cooks,  etc.).  If  any  work  is  done  at  the  home  the  nurse  makes 
sure  that  no  one  is  endangered  thereby. 

If  the  case  is  suitable  for  hospital  or  sanatorium  care,  she  endeavors 
to  induce  the  patient  to  enter  an  institution  voluntarily,  and  submits 
a  recommendation  to  that  efifect.  All  the  above  information  is  sub- 
mitted by  the  nurse  on  the  history  card. 

The  nurse  may  be  called  on  to  deliver  admission  cards  to  tuberculosis 
hospitals  to  patients,  and  instruct  them  how  best  to  reach  the  hospital, 
and  as  to  outfit  required. 

The  nurse  devotes  a  certain  portion  of  her  time  to  work  in  the  clinic. 
She  thus  familiarizes  herself  with  the  medical  aspect  of  her  cases,  and 
her  presence  tends  to  promote  friendly  relations  between  the  clinic,  the 
patients  and  herself.  She  also  calls  the  attending  physicians'  attention 
to  anything  specially  worthy  of  note  regarding  the  patients  and  their 
home  surroundings. 

The  history  card,  already  mentioned,  gives  a  description  of  the 
house,  the  rooms,  the  family,  the  financial  conditions,  the  physical  con- 
dition of  the  patient,  precautions  observed,  instructions  given,  and  any 
recommendations. 

One  of  these  cards  is  given  out  for  every  new  assignment  (including 


174  A  MANUAL  FOR  HEALTH  OFFICERS 

dead. cases,  those  removed  to  the  hospital  or  sanatoria,  etc.)-  Duplicate 
histories  are  made  out  for  all  cases  attending  the  tuberculosis  clinic. 
Sometimes  the  patient  will  give  a  friend's  or  relative's  address,  where 
he  has  never  lived.  The  history  card  is  not  filled  out  in  such  cases, 
unless  the  patient  be  seen.  A  new  card  is  assigned  whenever  a  patient 
changes  his  address,  returns  home  after  a  considerable  absence,  or  when 
conditions  at  home  have  changed. 

When  cases  under  care  of  private  physicians  are  visited  to  order  dis- 
infection, etc.,  only  the  house  history,  location  of  rooms,  how  long  the 
family  has  been  in  rooms,  previous  address,  and  name  and  address  of 
physician  or  clinic  caring  for  patient,  are  entered  on  the  card.  But 
when  such  cases  are  visited  on  complaint  a  full  history  is  taken. 

All  recommendations  are  entered  on  history  card,  it  being  the 
official  medium  for  handing  in  all  recommendations. 

Every  nurse  submits  a  daily  report  of  her  work  for  the  preceding 
twenty-four  hours.  This  report  gives  date,  name,  and  district  of 
nurse,  total  number  of  new  visits,  revisits,  and  extra  visits,  the  name 
and  address  of  each  patient  visited,  and  the  hour  when  nurse  reached 
the  premises.  On  the  reverse  of  the  card  is  given  a  summary  of  the 
day's  work,  and  the  total  number  of  hours  on  duty,  subdivided  into 
(i)  on  district,  (2)  at  clinic,  and  (3)  at  office.  At  the  close  of  each 
week,  the  totals  of  the  various  items  in  the  summary  on  the  daily  report 
are  entered  on  a  weekly  record  sheet,  which  shows  at  a  glance  the 
amount  and  kind  of  work  being  done  by  each  nurse.  Each  sheet 
covers  a  period  of  fifty-two  weeks. 

Throughout,  the  nurse  works  in  close  cooperation  with  health  de- 
partment, physician,  clinic  physician,  health  officer  and  inspectors. 
When  the  patient  is  bed-ridden  and  requires  regular  nursing  she  arranges 
for  it  with  the  district  nursing  organization.  She  also  applies  for 
charitable  aid  when  necessary. 

Duties  of  Health  Department  Physician  Relative 
TO  Tuberculosis.  —  The  health  department  physician  acts 
as  medical  inspector  in  tuberculosis;  he  may  also  act  as 
clinic  physician. 

All  suspected  cases  of  tuberculosis  that  will  not  or  cannot  visit  the 
clinic  may  be  examined  at  their  homes  by  the  physician.  These  cases 
are  reported  to  the  department  of  health  by  lay  organizations,  citizens, 
district  nurses,  inspectors  of  other  city  departments,  etc.  The  physi- 
cian submits  a  full  history  of  the  case  on  a  history  card.  If  a  new  case, 
a  regular  physician's  report  is  also  made  out.  Should  the  case  prove 
not  to  be  one  of  tuberculosis  the  words  "  not  tuberculosis  "  are  written 


COMMUNICABLE   DISEASE  1 75 

on  the  upper  left-hand  corner  of  the  face  of  the  history  card.  Any 
recommendations  and  special  notes  arc  written  on  the  card.  Should 
cleansinj^,  renovation,  or  disinfection  Ijc  necessary,  it  is  ordered. 

All  special  com])laints,  rcc|ucsts  for  hosjjital  care,  etc.,  are  investi- 
gated by  the  physician,  a  history  card  l)einji;  made  out  in  every  instance. 

Cases  of  i)iilmonary  tuberculosis  in  children  under  si.xtccn  years  of 
age,  in  which  the  attending  physician  will  not  certify  in  writing  that 
patient  can  safely  attend  school,  where  the  patients  will  not  or  cannot 
visit  the  clinic,  or  where  a  specimen  of  sputum  is  refused,  are  assigned 
to  the  physician.  They  are  visited  and  examined,  and  a  hi.story  card 
made  out  with  a  recommendation  as  to  what  action  should  be  taken 
by  the  department.  In  investigating  cases  reported  by  the  tuberculosis 
clinic  for  exclusion  or  readmisslon  to  school,  the  inspector  consults  with 
and  obtains  all  information  possible  from  the  clinic  before  visiting  the 
child. 

The  physician  should  also  examine  the  children  in  the  families  of 
consumptives  when  there  is  no  private  physician. 

The  tuberculosis  clinic  is  sometimes  requested  to  send  a  physician 
to  visit  a  clinic  patient  who  is  too  ill  to  attend  the  clinic.  Such  calls 
are  assigned  to  the  physician,  who  visits  the  patient,  prescribes  if  neces- 
sary, and  makes  out  a  history  card  recommending  suitable  action  (usu- 
ally removal  to  hospital).  But  the  physician  does  not  render  continued 
medical  service  at  the  home.  Monthly  visits  to  patients  living  in  lodg- 
ing houses  are  made  by  the  physician  on  request  of  the  nurse.  Some 
of  the  cases  requiring  continued  medical  care  but  not  sent  to  the  hos- 
pital may  be  referred  to  the  town  poor  physician. 

When  forcible  removal  to  hospital  of  a  case  of  pulmonary  tuberculosis 
is  ordered,  the  physician  makes  all  necessary  arrangements,  and  is 
present  at  the  removal.  If  in  his  opinion  the  patient  is  in  a  dying  con- 
dition, he  may  suspend  removal,  submitting  a  written  report  to  that 
effect. 

When  notice  is  received  that  a  given  case  of  tuberculosis  has  recov- 
ered, and  no  physician's  certificate  is  forwarded,  the  case  is  assigned 
to  the  physician  to  visit  and  make  a  physical  examination.  He  sub- 
mits a  history  card  as  above  stated. 

Cleansing  and  Disinfection.  —  After  the  death  or 
removal  of  a  tuberculosis  patient  the  room  or  rooms  which 
have  been  occupied  by  him  require  attention.  Deaths 
should  be  noted  from  the  death  certificates,  and,  as  already 
mentioned,  the  law  should  require  that  physicians,  land- 
lords, etc.,  give  prompt  notice  of  the  removal  of  patients 


176  A  MANUAL  FOR  HEALTH  OFFICERS 

when  known  to  them.  In  default  of  such  procedure  the 
removal  of  many  cases  is  discovered  only  by  the  tubercu- 
losis nurse. 

The  following  processes  should,  so  far  as  required,  be 
applied  to  infected  rooms: 

(a)  Cleaning-up,  involving  scrubbing  of  floors  and  wood- 
work, removal  of  dust  by  moist  methods  or  vacuum,  and 
airing. 

(b)  Application  of  simple  disinfectant,  such  as  crude 
carbolic  or  coal-tars  in  known  strength,^  to  surfaces  which 
have  been  exposed  to  infection  by  handling,  etc.;  appro- 
priate disinfection  (or  destruction)  of  miscellaneous  articles 
which  have  been  exposed  to  infection;  similar  treatment 
for  bedding. 

(c)  Formaldehyde  fumigation,  for  disinfection  of  car- 
pets, fabrics  and  surfaces  not  susceptible  of  treatment  under 
above  heads. 

More  or  less  general  house-cleaning  and  disinfection  may 
also  be  required. 

Between  the  time  when  the  patient  departs  and  the  com- 
pletion of  the  measures  ordered  it  is  frequently  the  custom 
to  placard  the  apartments  with  a  warning  that  they  are 
not  to  be  reoccupied  until  the  health  department  orders 
have  been  carried  out  and  the  placard  removed  by  nurse 
or  inspector. 

In  some  exceptional  cases,  when  the  apartment  is  in  good 
order  and  the  patient  has  stayed  only  one  or  two  nights, 
cleansing  and  disinfection  measures  may  be  omitted.  In 
other  such  cases  a  simple  formaldehyde  disinfection  suffices. 

Formaldehyde  disinfection  is  performed  by  the  health 
department;  cleansing  and  application  of  liquid  disinfect- 
ants by  the  occupants,  with  assistance,  if  necessary,  from 
health  or  charity  authorities.  Needed  disinfectants  should 
be  furnished  free  of  charge  by  the  health  authorities. 

^  See  Appendix  A.  Coal-tars  may  be  added  to  the  soap  and  water 
used  for  cleansing. 


COMMUNICAHI-K    DISICASK  177 

In  the  course  of  weeks  and  months  it  is  not  unh'kely 
that  carpets,  bedding,  curtains,  and  other  furnishings  may 
become  infected  with  tubercle  baciUi,  and  special  attention 
shoukl  be  paid  to  articles  of  this  class.  Infected  articles 
of  this  class  which  cannot  be  readily  disinfected  may,  if 
of  little  value,  be  destroyed.  The  same  rule  applies  to 
all  articles  of  small  value  which  have  been  in  contact  with 
or  near  the  patient. 

Tubercle  bacilli  in  dried  sputum  may  live  for  months, 
and  thus  disinfection  is  of  greater  value  after  this  disease 
than  after  others  whose  viruses  die  much  more  quickly. 
However,  cleanliness  is  as  important  as  simple  disinfection, 
and  thorough  cleansing  is  far  more  truly  disinfecting  than 
a  superficial  so-called  disinfection. 

3.  Institutional  Care.  —  Clinics  and  Dispensaries.  — 
Among  the  various  kinds  of  institutions  for  the  care  of 
tuberculosis,  we  may  mention  first  the  clinic  or  dispen- 
sary. With  the  tuberculosis  nurse  the  dispensary  stands 
as  the  most  important  single  local  agency  for  the  detection 
and  treatment  of  the  disease.  Persons  who  cannot  afford 
the  services  of  a  private  physician  will  visit  a  clinic  with 
much  benefit.  Through  it,  also,  the  nurse  has  a  means  of 
keeping  in  regular  touch  with  the  patients  and  their  con- 
dition. The  clinic  is  usually,  though  not  necessarily,  oper- 
ated in  connection  with  a  general  hospital.  The  details  of 
operation  cannot  be  entered  upon  here.  Patients  in  all 
stages  may  be  kept  under  care,  while  the  detection  of  in- 
cipient cases  is  an  especially  important  function  of  the  clinic. 

Sanatoria  and  Hospitals.  —  For  incipient  and  only 
moderately  advanced  cases  there  is  the  sanatorium.  We 
do  not  refer  to  the  many  private  sanatoria  which  exist, 
but  to  the  public  sanatorium  to  which  indigent  persons  and 
persons  of  small  means  may  go  for  the  "cure."  Every 
community  should  be  able  to  send  its  cases  to  such  an  in- 
stitution, whether  it  be  maintained  locally  or  by  state  or 
county.     The  regimen  prescribed  at  the  sanatorium  has 


178  A  MANUAL  FOR  HEALTH  OFFICERS 

the  abject,  not  only  of  cure,  but  also  of  inculcating  correct 
habits,  so  that  when  the  patient  returns  home  he  will  live 
according  to  hygienic  principles,  and  by  his  example  lead 
Qthers  to  do  so. 

Patients  returning  from  sanatoria  should  be  "followed 
up"  by  the  tuberculosis  nurse,  as  they  tend  to  relapse  into 
their  former  condition  and  habits.^ 

Advanced  cases  are  usually,  though  not  necessarily,  cared 
for  in  a  separate  hospital.  It  is  of  the  greatest  importance 
that  provision  for  the  hospital  care  of  advanced  cases  be 
made  in  every  community.  Where  one  community  is  un- 
able to  maintain  such  a  hospital  alone,  it  may  arrange  with 
others  to  maintain  a  joint  hospital,  or  there  may  be  estab- 
lished a  county  institution.^ 

The  most  important  elTect  of  sanatoria  and  hospitals  as 
regards  the  public  health  is  the  segregation  of  infectious  per- 
sons. But  the  cure  (so  far  as  possible)  of  those  persons  and 
their  return  in  a  relatively  able  and  non-infectious  condi- 
tion are  also  important  considerations  in  the  social  problem 
due  to  tuberculosis.  The  object  of  segregation  applies 
with  special  force  to  the  advanced  cases,  which  shed  the 
germs  in  much  greater  numbers.  It  sometimes  occurs 
that  the  curable  cases  are  looked  after  while  the  very  ad- 
vanced and  potently  infectious  cases  have  comparative 
freedom  to  spread  the  disease. 

Progress  in  regard  to  segregation  measures  has  been  slow 
for  the  reason  that  the  public  has  only  lately  become  con- 
vinced that  tuberculosis  is  a  truly  communicable  disease, 
and  that,  while  it  may  not  be  subject  to  the  same  rigid 
isolation  as  some  other  communicable  diseases,  it  neverthe- 
less demands  strict  prophylactic  measures.  When  the 
rules  laid  down  for  home  life  (see  above)  are  obeyed  and 
the  patient  can  live  a  proper  life  at  home  without  mate- 

1  This  danger  was  brought  out  by  investigations  in  Massachusetts. 
See  Am.  Jour.  Pub.  Health,  1912,  vol.  II,  no.  6,  p.  494. 

2  See  note,  next  page. 


COMMUNICABLE  DISEASE  179 

rially  endangering  others,  then  well  and  goorl.  liiit  if  a 
proper  regimen  cannot  be  ol)taine(l  at  h(;me,  and  espe- 
cially when  the  patient,  through  invincible  ignorance  or  care- 
lessness, is  a  menace  to  others,  then  hospital  segregation  is  a 
necessity.  It  follows  that  healtli  authorities  should  have 
the  power,  when  persuasion  fails,  to  remove  such  cases  to 
the  hospital.  The  following  are  the  grounds  for  forcible 
removal  and  hospital  detention  in  New  York  City,  which  has 
practiced  such  removal  since  1901 :  (a)  that  the  patient's 
sputum  contains  tubercle  bacilli;  {b)  that  the  patient 
either  will  not  or  cannot  observe  the  necessary  precautions 
as  to  disposal  of  sputum;  and  (c)  that  others  (especially 
children)  are  exposed  to  infection.  If  all  of  these  condi- 
tions exist  removal  is  deemed  necessary.  In  New  Jersey 
a  recent  statute  provides  that  the  State  Board  of  Health 
may  lay  down  certain  rules  to  be  observed  by  tuberculosis 
patients,  that  such  rules  are  to  be  imparted  to  the  patient 
by  the  local  health  authorities,  and  that  if  the  patient  per- 
sistently disregards  them  he  may,  upon  due  process  of  law, 
be  removed  to  the  segregation  hospital.  The  law  further 
makes  mandatory  the  establishment  of  a  tuberculosis 
hospital  in  each  county.'^ 

1  "  The  New  Jersey  bill  providing  for  compulsory  segregation  of 
tuberculosis,  has  been  signed  by  Governor  Wilson  and  is  now  in  force. 
The  law  is  without  doubt  the  most  advanced  state  legislation  on  tuber- 
culosis that  has  ever  been  enacted  in  this  country,  if  not  in  the  world. 

"  The  new  law  provides  that  tuberculosis  patients  who  refuse  to 
obey  the  regulations  laid  down  by  the  State  Board  of  Health  concern- 
ing the  prevention  of  their  disease,  and  thus  become  a  menace  to  the 
health  of  those  with  whom,  they  associate,  shall  be  compulsorily  segre- 
gated by  order  of  the  courts,  in  institutions  provided  for  this  purpose. 
If  such  a  patient  refuses  to  obey  the  rules  and  regulations  of  the  institu- 
tion in  which  he  is  placed,  he  may  '  be  isolated  or  separated  from  other 
persons  and  restrained  from  leaving  the  institution.'  The  State  Board 
of  Health,  working  through  the  local  boards  is  given  the  power  to  en- 
force the  provisions  through  the  courts.  The  law  further  provides  that 
all  counties  in  the  State  of  New  Jersey  shall  within  six  months  from 
April  1st,  make  provision  in  special  institutions  for  the  care  of  all  per- 


I  So  A  MANUAL  FOR  HEALTH  OFFICERS 

It  is  unfortunate  that  there  is  a  popular  mistrust  of 
tuberculosis  hospitals  —  we  refer  particularly  to  those  for 
advanced  cases  —  on  the  part  of  patients.  This  mistrust 
is  very  likely  owing  to  the  fact  that  such  hospitals  are 
sometimes  conducted  in  conjunction  with  general  conta- 
gious disease  hospitals,  that  they  become  known  as  hospi- 
tals for  hopeless  cases,  and  that  patients  returning  from 
them  describe  the  conditions  as  depressing.  Some  of  these 
objections  would  be  removed  if  cases  in  all  stages  were 
treated  in  the  same  institution,  being  simply  separated  in 
pavilions.  Such  an  institution  should  be  quite  separate 
and  distinct  from  the  isolation  hospital  for  other  diseases; 
and  if  conditions  were  made  as  cheerful  as  possible  there 
should  be  none  of  the  present  popular  objections,  and  com- 
pulsory removal  to  the  hospital  would  rarely  be  necessary. 
It  might  thus  also  be  possible  to  avoid  the  name  "hospi- 
tal" in  favor  of  the  more  euphemistic  title  "sanatorium." 
Such  institutions  should  be  convenient  to  centers  of  popu- 
lation. 

sons  having  tuberculosis  in  these  counties.  The  state  treasury  will 
subsidize  each  county  to  the  extent  of  $3.00  a  week  for  each  person 
maintained  in  these  institutions  except  those  who  are  able  to  pay  for 
the  cost  of  maintenance. 

"  The  only  other  state  which  provides  for  compulsory  segregation 
of  dangerous  cases  of  tuberculosis,  is  Maryland.  The  only  city  in 
the  United  States  which  has  adopted  a  special  ordinance  providing  for 
compulsory  removal  of  dangerous  tuberculosis  cases,  is  San  Francisco. 
A  few  other  cities,  such  as  New  York,  exercise  this  power  under  certain 
provisions  of  their  sanitary  codes,  but  no  other  city  has  any  special 
ordinance  on  the  subject. 

"  New  Jersey  now  [1912]  has  two  county  hospitals  in  operation,  one 
in  building  and  one  about  to  be  started.  It  is  expected  that  the  new  law 
will  materially  increase  the  number  of  such  institutions  because  of  its 
mandatory  character.  Anti-tuberculosis  workers  will  also  watch  with 
much  interest  the  way  in  which  the  provisions  for  compulsory  segrega- 
tion and  detention  work  out."  (Statement  of  National  Association  for 
the  Study  and  Prevention  of  Tuberculosis,  quoted  in  Am.  Jour.  Pub. 
Health,  May,  191 2.)  New  York  State  also  now  has  such  a  law 
(1914)- 


COMMUNICABLE   DISEASE  i8i 

Other  Agencies.  —  Mention  at  Icnj^lli  nccfl  noi  ho 
made  of  the  various  other  agencies  existing  for  tlie  treat- 
ment or  preventi(Mi  of  tuberculosis.  There  are  day  camps 
for  tuberculous  children  and  adults,  outdoor  sleeping 
colonies,  "preventoria,"  and  the  like,  conducted  for  the 
most  part  by  voluntary  organizations.  The  Association  for 
Improving  the  Condition  of  the  Poor,  of  New  York  City, 
has  carried  out  some  experiments  to  demonstrate  how  poor 
people  may  be  cared  for  in  their  homes. ^  In  the  schools 
the  "fresh  air"  movement  has  resulted  in  the  establish- 
ment of  open-air  classes  for  children  who  are  anaemic  or 
not  up  to  physical  par,  and  separate  open-air  classes  for 
children  having  latent  tuberculosis.  The  essential  points 
in  the  regimen  are  work  and  rest  in  very  freely  ventilated 
rooms  (sitting-out  bags  and  the  like  being  provided  in  cold 
weather)  and  nutritious  lunches.  The  results  in  physical 
gain  obtained  in  such  classes  are  in  many  cases  very  strik- 
ing. Diet  kitchens  and  similar  institutions  which  furnish 
milk  and  eggs  at  cost  or  free  to  needy  tuberculosis  patients 
deserve  mention  as  parts  of  the  general  scheme.  Play- 
grounds and  all  other  agencies  which  tend  to  promote 
health  and  vital  resistance  are  valuable  factors  in  the  anti- 
tuberculosis movement. 

The  condition  of  the  mouth  and  teeth  of  consumptives  is  of 
great  importance,  and  dental  clinics  should  be  available,  both 
for  hospital  applicants  and  for  patients  remaining  at  home. 

4.  Popular  Educational  Measures.  —  Popular  education 
is  of  greater  value  in  relation  to  tuberculosis  than  to  per- 
haps any  other  preventable  disease.  Since  many  of  the 
conditions  favoring  tuberculosis  can  be  obviated  or  dealt 
with  by  the  citizen  —  and  particularly  those  involved  in 
personal  hygiene  —  the  benefits  of  publicity  are  evident. 
Furthermore,  the  principles  of  prevention  are  simple  and 
lend  themselves  readily  to  publicity  methods. 

^  "  The  Howe  Hospital  Experiment,"  1914,  Assn.  Imp.  Cond. 
Poor,  105  E.  22nd  St.,  N.  Y.  City. 


1 82  A  MANUAL   FOR  HEALTH  OFFICERS 

Various  means  of  piiblicity  suggest  themselves.  Leaflets, 
cards,  posters,  and  other  printed  matter  may  be  distributed 
at  lectures,  through  the  schools,  in  stores,  and  so  forth. 
Then  there  should  be  lectures,  preferably  illustrated.^ 
Special  benefits  are  obtained  through  informal  talks  given 
in  schools,  in  factories,  before  labor  organizations,  clubs, 
and  the  like.  If  there  is  a  local  moving  picture  theater, 
the  interest  of  the  manager  should  be  secured  to  show  one 
or  more  of  the  films  dealing  with  tuberculosis,  the  perform- 
ances being  publicly  approved  by  the  health  officer. 

It  is  now  the  custom  of  the  National  Association  for  the 
Study  and  Prevention  of  Tuberculosis  to  appoint  annually 
in  the  spring  a  "tuberculosis  day,"  which  should  be  the 
occasion  of  special  efforts  in  publicity  work,  particularly 
through  meetings,  addresses,  exhibits,  etc.,  the  health 
authorities  cooperating  with  local  organizations.  In  the 
schools  brief  talks  suited  to  the  intelligence  of  the  various 
classes  and  emphasizing  the  value  of  the  simple  principles 
of  personal  hygiene  may  be  given,  and  the  pupils  may 
write  essays,  perhaps  for  prizes.  On  this  annual  occasion 
the  aim  is  not  to  obtain  funds  for  tuberculosis  work,  but 
popular  education  pure  and  simple. 

Exhibitions  or  small  exhibits,  separate  or  in  connection 
with  general  exhibitions,  are  of  great  value.  They  should 
be  graphic,  simple,  and  not  "gruesome"  but  emphasizing 
hopeful  principles,  and  may  be  the  occasion  of  talks  and 
distribution  of  literature. 

And  in  all  of  this  the  invaluable  cooperation  of  the  news- 
paper press  should  be  obtained.  For  further  remarks  on 
publicity  work  see  Chapter  X. 

As  to  the  ideas  to  he  set  forth,  which  should  be  simple, 
the  following  points  should  be  specially  dwelt  upon: 

^  The  Nat.  Assn.  for  Study  and  Prevention  of  Tuberculosis,  105 
East  22nd  St.,  New  York,  furnishes  a  Hst  of  slides  which  may  be  ob- 
tained through  it,  also  information  regarding  tuberculosis  motion 
pictures. 


COMMUNFCABLK    DISKASE  183 

(1)  Warning  avS  to  the  general  nature  of  the  disease  and 
the  conditions  which  favor  it. 

(2)  The  importance  of  recognizing  the  early  symptoms; 
and  insistence  on  the  fact  that  tuberculosis  in  its  early 
stages  is  curable,  while  in  the  later  stages  arrest  or  cure  is 
difficult  when  not  impossible.  One  of  the  chief  hopes  in 
the  tuberculosis  campaign  lies  in  the  earlier  recognition  of 
cases  (thereby  promptly  indicating  sources  of  infection  and 
leading  to  steps  to  restore  the  patients  themselves  to  health). 
This  depends  partly  upon  the  establishment  and  recogni- 
tion of  dispensary  facilities  for  the  poor  who  would  other- 
wise have  no  medical  attention,  but  most  of  all  upon  the 
individual  himself. 

(3)  The  value  of  hygienic  habits  regarding  fresh  air, 
proper  exercise,  food  and  rest,  temperance  in  all  things,  and 
other  conditions  which  promote  vital  resistance.  These 
factors,  in  varying  kind  and  degree,  apply  both  in  prevent- 
ing the  disease  in  the  well  and  in  treating  the  sick. 

(4)  Condemnation  of  the  unnecessary,  filthy  and  dan- 
gerous promiscuous  spitting  upon  public  sidewalks,  in 
public  buildings,  and  the  like.  The  board  of  health  should 
forbid  it  by  an  effective  ordinance,  to  which  public  atten- 
tion should  be  called.  While  the  virulence  of  tubercle 
bacilli  in  dust  is  still  in  dispute,  it  needs  no  argument  to 
show  that  sputum  from  sidewalks  may  be  tracked  into 
houses  on  shoes  and  skirts,  there  to  infect  the  floor  upon 
which  children  play  and  very  possibly  the  house  atmos- 
phere. And  since  there  is  no  way  of  recognizing  who  are 
tubercle-distributors  and  who  are  not,  promiscuous  spitting 
should  be  forbidden  to  all  at  all  times.  In  the  streets, 
persons  may  of  course  spit  in  the  gutters;  in  public  build- 
ings, offices,  etc.,  destructible  (or  at  least  readily  cleansable) 
cuspidors  should  be  provided.  The  old-fashioned  cuspidor, 
designed  for  appearance  rather  than  facility  of  keeping 
clean,  may  be  replaced  by  the  impervdous  paper  variety 
now  on  the  market,  or  by  sawdust  in  boxes,  both  of  which 


1 84  A  MANUAL  FOR  HEALTH  OFFICERS 

require  no  disinfectants  and  may  be  periodically  collected 
and  burned. 

5.  Sanitary  Supervision  of  Dwellings,  etc.  —  Under  this 
head  we  include  supervision  of  dwelling  houses  (particu- 
larly tenements),  factories,  schools,  etc.,  a  subject  which 
will  be  taken  up  in  a  later  chapter.  Cleanliness,  light,  and 
ventilation  are  the  chief  points.  All  measures  promoting 
the  general  health  of  the  population,  being  effective  against 
tuberculosis,  may  also  be  mentioned  here. 

6.  Prevention  of  Tuberculosis  Infection  through  Milk.  — 
The  proportion  of  tuberculosis  derived  from  milk  is  esti- 
mated at  about  7  per  cent.  This  subject  will  be  taken  up 
in  detail  in  Chapter  III,  under  Milk  Supplies. 

7.  General  Cooperation  of  All  Anti-Tuberculosis  Agen- 
cies. —  At  the  present  time  a  great  deal  of  work  in  the 
tuberculosis  campaign  is  being  carried  on  by  voluntary 
organizations.  Some  of  this  is  work  which  should  be  — 
and  in  future  will  increasingly  be  —  maintained  by  the 
health  authorities  by  means  of  public  funds,  though  a 
certain  proportion  will  doubtless  fittingly  remain  under 
the  control  of  private  organization.  The  health  officer 
should  foster  close  cooperation  with  all  of  these,  exchanging 
reports,  data,  etc.  He  should,  moreover,  in  consultation 
with  the  various  organizations,  work  out  a  detailed  plan 
by  which  the  whole  work  in  tuberculosis  is  coordinated  and 
systematic  relationships  and  functions  are  established. 

In  conclusion,  we  may  note  the  progress  already  made  in 
the  tuberculosis  movement  and  the  hopeful  auguries  for 
the  future.  The  most  recent  census  mortality  statistics 
show  that  the  tuberculosis  death  rate  for  the  Registration 
States  decreased  from  189  per  100,000  population  in  1901 
to  159  in  191 1.  In  New  York  City  the  decrease  was  from 
230  to  175.  Hoffman  has  recently  shown  that  since  1881 
the  death  rate  from  tuberculosis  in  American  cities  (ex- 
cluding the  colored  population)  has  dropped  off  fifty  per 


COMMUNICABLE   DISEASE  1 85 

cent.^  While  it  would  be  (juile  unw.irraiiLahh-  to  ascribe 
all  of  the  decrease  to  sanitary  control  —  for  allowance  must 
be  made  for  improved  diagnosis,  treatment,  living  condi- 
tions, etc.  —  nevertheless  the  effects  of  the  tuberculosis 
campaign  are  distinctly  being  felt. 

The  proportion  of  public  (as  compared  with  private) 
funds  now  stands  at  about  three-quarters  of  the  total 
spent  on  tuberculosis  work  and  is  steadily  increasing. 

The  public  attitude  is  hopeful,  in  that  knowledge  of  the 
means  of  prevention  is  now  much  more  widespread  than 
ever  before.  It  is  doubtful,  indeed,  whether  some  of  the 
popular  propaganda  has  not  been  carried  to  an  excess. 
Thus,  for  example,  the  idea  of  the  communicability  of  the 
disease  has  given  rise  to  the  perversion  of  "phthisiophobia" 
(fear  of  consumption),  which  leads  to  unnecessary  ostra- 
cism of  practically  harmless  patients.  Such  fear  has  also 
made  it  unnecessarily  difficult  to  establish  sanatoria  and 
hospitals  near  other  dwellings.  To  dispel  such  ideas  it 
should  be  taught  that  practically  nothing  is  to  be  feared, 
even  in  the  family,  from  a  consumptive  if  the  necessary 
precautions  are  strictly  followed  out;  and  that  there  is  no 
danger  from  ordinary  tuberculosis  institutions.  It  is  fre- 
quently advantageous  to  locate  such  institutions  in  built-up 
districts,  and  no  reasonable  opposition  should  be  encoun- 
tered.^ 

While  the  future  is  hopeful,  a  word  of  caution  is  in  order. 
The  leaders  in  the  tuberculosis  movement  deprecate  over- 
enthusiastic  expectations  of  declines  in  case-  and  death- 
rates.  Many  factors  are  involved  —  social,  economic, 
hygienic  —  many  of  them  beyond  the  control  of  the  public 

^  F.  L.  Hoffman,  "  The  Decline  in  the  Tuberculosis  Death  Rate  " 
(abstract  of  a  paper  read  before  the  National  Association  for  the  Study 
and  Prevention  of  Tuberculosis,  May,  1913),  Jour,  of  the  Outdoor  Life, 
December,  19 13.     (See  also  editorial  in  same  issue.) 

*  See  "  The  Effect  of  Tuberculosis  Institutions  on  The  \'alue  and 
Desirability  of  Surrounding  Property,"  Nat.  Assn.  for  Study  and  Prev. 
of  Tub.  (pamphlet,  locts.). 


1 86  A  MANUAL  FOR  HEALTH  OFFICERS 

authorities  —  and  each  successive  diminution  of  the  rate 

becomes    more    difficult.     Still,    thorough    application    of 

principles  now  recognized  will  bring  great,  though  gradual, 

results. 

REFERENCES 

The  literature  of  tuberculosis  is  very  extensive,  and  we  can  here 
give  only  a  few  leading  references,  necessarily  omitting  a  number  of 
works  of  value,  especially  those  of  a  more  or  less  popular  character, 
as  well  as  those  on  medical  aspects,  which  would  be  included  in  a  longer 
list. 

Perhaps  the  simplest  general  presentation  (non-technical,  but 
thorough)  is  contained  in  Knopf's  "  Tuberculosis  as  a  Disease  of  the 
Masses,  and  How  to  Combat  It,"  International  Prize  Essay,  obtainable 
of  the  Survey,  105  East  22nd  St.,  N.  Y.  City  (25  cents).  Also  printed 
in  foreign  languages.  Especially  useful  as  a  basis  for  publicity.  By 
the  same  author:  "  Tuberculosis:  a  Preventable  and  Curable  Disease 
—  Modern  Methods  for  the  Solution  of  the  Tuberculosis  Problem  " 
(Moflfat  Yard  and  Co.). 

Newsholme,  "  The  Prevention  of  Tuberculosis  "  (Dutton). 

Von  Behring,  "  The  Suppression  of  Tuberculosis  "  (translated  by 
Bolduan). 

Billings,  "  Handbook  of  Help  for  Persons  Suffering  from  Pulmonary 
Tuberculosis  "  (J.  W.  Pratt  Co.). 

Carrington,  "  Fresh  Air  and  How  to  Use  It  "  (Nat.  Assn.  for  Study 
and  Prevent,  of  Tub.). 

Rogers,  "  A  Working  Program  for  a  Small  City  "  (State  Charities 
Aid  Assn.,  105  East  22nd  St.,  N.  Y.  City). 

Carrington,  "  Tuberculosis  Hospital  and  Sanatorium  Construction  " 
(Nat.  Assn.  for  Study  and  Prevent,  of  Tub.). 

Various  publications  of  the  National  Association  for  Study  and  Pre- 
vention of  Tuberculosis,  105  East  22nd  St.,  New  York  City  (Ann. 
Transactions,  Directory  of  associations,  etc.  and  legislation  in  U.  S., 
Journal  of  the  Outdoor  Life,  Monthly  Bulletins,  etc.,  also  Transactions 
of  the  International  Congress  on  Tuberculosis,  1908).  For  information  on 
special  topics  in  the  tuberculosis  campaign  (e.g.,  local  organization,  leg- 
islation, etc.)  apply  to  the  National  Association.  Various  State  Associa- 
tions also  issue  useful  literature. 

Papers  in  Transactions  of  the  X  V  International  Congress  on  Hygiene 
and  Demography ,  1912,  vol.  IV,  pt.  I. 

Other  diseases  of  this  class  —  such  as  influenza,  common 
colds,  mumps,  etc.  —  may  be  spread  by  contact  infection. 


COMMUNICAI'.I.I',    DISKASI-:  187 

but  do  not  require  action  by  licalth  aiillioritics;  alllioii^h  in 
some  places  quarantine  is  reciuircd  for  mumps.  Influ(;nza 
("grippe")  is  readily  communicable,  has  many  carriers 
and  is  an  important  cause  of  death  in  infants  and  the 
aged,  facts  to  which  public  attention  should  be  called. 
Smallpox  is  considered  under  Section  IV. 

II.  DISEASES    SPREAD    LARGELY    THROUGH 
EXCRETA 

TYPHOID   FEVER 

Typhoid  fever  (enteric  fever)  is  the  principal  of  the  dis- 
eases spread  through  the  alvine  discharges  (feces  and  urine), 
and  constitutes  one  of  the  most  serious  sanitary  problems 
in  the  United  States  to-day. 

Typhoid  fever  is  an  infection  due  to  the  Bacillus  typhosus 
(or  typhi),  commonly  called  the  typhoid  bacillus,  which 
enters  the  body  through  the  alimentary  canal  and  is  shed 
off  in  the  feces  and  urine  of  the  typhoid  patient.  Typhoid 
fever  does  not  arise  spontaneously  from  filth,  although 
propagated  through  infected  filth;  every  case  is  derived 
from  an  antecedent  case.  While  the  bacillus  primarily 
enters  and  proliferates  in  the  mucous  membranes  of  the 
intestines,  it  produces  a  general  systemic  infection  which 
attacks  other  organs,  with  more  or  less  acute  symptoms  of 
fever,  intestinal  disturbance,  collapse,  etc.  It  is  not  infre- 
quently complicated  with  other  diseases  —  e.g.,  pneumonia, 
the  deaths  from  which  are  sometimes  reported  as  due  to 
"typhoid  pneumonia,"  an  incorrect  term.  The  effect  of 
typhoid  in  lowering  vital  resistance  produces  a  liability  to 
other  diseases,  such  as  tuberculosis.^ 

^  Dublin  {Am.  Jour.  Pub.  Health,  191 5,  vol.  V,  no.  i,  p.  20)  estimates 
that  in  the  United  States  "  each  year  a  minimum  of  close  to  8000  deaths 
occur  which  can  be  attributed  to  the  impairments  which  follow  t\"phoid 
fever." 


1 88  A  MANUAL  FOR  HEALTH  OFFICERS 

Transmission.  —  The  typhoid  bacilli  commonly  leave 
the  patient  mainly  in  the  feces  and  urine. ^  The  feces  must 
be  regarded  as  infected  throughout  the  duration  of  the 
disease,  from  even  before  the  fever  and  until  convalescence 
is  complete.  The  bacilli  commonly  appear  in  the  urine 
some  time  after  the  onset  of  the  disease;  hence  the  urine 
also  should  be  regarded  as  infected  throughout  the  course 
of  fever  and  convalescence. 

The  patient  commonly  ceases,  during  convalescence,  to 
be  infectious.  In  some  instances,  however,  the  emission 
of  germs  continues  after  recovery,  in  persons  who  become 
carriers.  The  whole  theory  of  carriers  and  mild  and  atypical 
infection,  as  already  discussed,  applies  to  typhoid  fever. 
Some  cases  are  so  mild  that  they  pass  unrecognized.  In 
others,  the  patient  is  unwell,  but  does  not  feel  ill  enough  to 
go  to  bed:  these  are  the  "walking  typhoid"  cases  which 
are  especially  dangerous  in  spreading  the  disease.  Finally, 
as  first  remarked,  there  are  the  recovered  carriers  who  con- 
tinue to  emit  virulent  typhoid  bacilli  in  the  feces  or  urine 
for  weeks,  months  or  even  years  after  apparent  recovery. 
"In  about  4  per  cent  of  all  cases  of  typhoid  fever  the  patient 
continues  to  shed  typhoid  bacilli  in  the  urine  or  feces  dur- 
ing and  after  convalescence  "  (Rosenau).  There  are  also 
carriers  who  give  no  history  of  ever  having  had  the  disease. 
We  shall  allude  to  the  carrier  problem  again  presently. 

The  bacilli  shed  by  the  sick  or  by  carriers  pass  to  the  well 
in  a  variety  of  ways,  direct  or  indirect,  mentioned  below. 
They  enter  the  mouth  with  some  article  of  food  or  drink, 
or  simply  by  carriage  to  the  mouth  by  infected  fingers. 

The  following  are  the  principal  modes  of  transmission: 

I.  Contact.  —  Typhoid  fever  is  contagious  in  the  sense 
that  it  can  pass  directly  from  patient  to  victim  by  certain 

^  As  to  other  discharges:  "  The  sputum  does  not  ordinarily  contain 
the  bacilli  unless  there  is  a  pneumonia  or  severe  bronchitis.  The  bacilli 
may  be  eliminated  with  the  discharges  from  abscesses,  such  as  periostitis, 
months  and  even  years  after  the  disease."     (Rosenau.) 


COMMUNICARLK    DFSKASK  189 

modes  of  contact  infection  (sec  page  1 13  ff.).  Vor  cx.unple, 
in  Washington,  D.  C,  careful  investigations  in  recent 
years  placed  the  amount  of  contact  infection  at  15  [)er 
cent  or  more  of  all  cases.  Incalculable  harm  has  been 
done  by  the  false  statement  that  "typhoid  fever  is  infec- 
tious but  not  contagious,"  implying  that  it  is  not  trans- 
mitted directly  from  one  person  to  another.  All  that  is 
necessary  is  that  the  infected  excreta  contaminate  the 
fingers  of  nurse  or  other  associate  of  the  patient,  or  some 
object  by  which  the  fingers  may  become  contaminated. 
Thence  infection  by  mouth  is  easy,  directly  from  the  fingers 
or  through  food  or  drink.  Thus  it  may  pass  just  as  easily 
from  person  to  person  as  diphtheria  or  scarlet  fever.  The 
patient  or  nurse  may  infect  food  to  be  eaten  by  other 
persons.  Such  is  all  true  contact  infection,  chiefly  through 
the  agency  of  infected  fingers. 

2.  Water.  —  We  pass  now  to  the  less  direct  but  never- 
theless highly  important  modes  of  transmission.  One  of 
the  chief  of  these  is  transmission  through  water.  Water- 
supplies  become  infected  through  the  improper  disposal 
of  the  undisinfected  excreta  of  typhoid  patients,  and  may 
then  spread  the  disease  very  widely.  Many  epidemics 
of  water-borne  typhoid  fever  are  on  record.  To  illustrate 
the  vast  dangers  of  water  infection,  note,  for  example,  the 
Plymouth,  Pa.,  epidemic  (page  278),  in  which,  through  the 
infection  of  a  town  water-supply,  a  single  case  gave  rise  to 
1 104  cases  with  1 14  deaths. 

Epidemics  of  water-borne  typhoid  fever  have  not  infre- 
quently been  foreshadowed  by  outbreaks  of  intestinal 
disease,  the  latter  occurring  some  days  in  advance  of  the 
former.  Thus  at  Rockford,  111.,  in  1912,  in  a  population 
of  45,000  there  occurred  some  10,000  cases  of  diarrhoeal 
disease,  followed  by  200  cases  of  typhoid  fever. 

Ice  may  also  be  considered  a  possible  vehicle  of  typhoid 
fever,  though  there  are  no  clear  epidemics  of  ice-borne 
typhoid  on  record.    In  the  one  epidemic  (Ogdensburg,  N.  Y.) 


igo  A  MANUAL   FOR   HEALTH  OFFICERS 

attributed  to  ice,  the  evidence  is  not  at  all  convincing  (page 
418).  The  reason  that  ice  has  not  figured  prominently  in 
typhoid  fever  transmission  doubtless  is,  that  both  the 
freezing  and  the  storage  of  ice  arc  bactcriologically  puri- 
fying processes. 

3.  Milk.  —  In  milk  we  again  find  a  dangerously  ready 
vehicle  of  infection  for  typhoid  fever.  Typhoid  bacilli 
readily  live  in  milk  and,  except  at  low  temperatures,  thrive 
in  it.  The  extreme  severity  of  some  milk-borne  epidemics 
in  which  the  original  infection  of  the  milk-supply  was 
slight  are  explained  by  the  multiplication  of  the  bacilli  in 
that  medium.  Many  extensive  epidemics  of  milk-borne 
typhoid  have  occurred  (page  281  ff.).  Supplies  become  in- 
fected through  cases  or  carriers  among  employees  in  dairies. 
or  milk-handling  establishments,  or  the  infection  may  be 
introduced  into  the  supply  indirectly  by  employees  who 
have  been  in  association  with  patients  or  carriers.  Milk 
bottles  or  other  apparatus  may  become  infected  through 
the  use  of  an  infected  water-supply  for  washing  them. 
Milk  bottles  may  also  be  infected  in  the  families  from  which 
they  are  collected.  In  an  instance  under  the  observation 
of  the  writer  such  bottles  apparently  infected  a  washing 
tank  and  other  bottles  washed  in  it. 

Milk  products  and  ice-cream  are  also  potential  vehicles 
of  the  disease. 

4.  Flies.  —  Flies  may  readily  convey  infection  from 
exposed  infected  excreta  to  food.  This  fact  is  expressed 
in  the  alliterative  or  catch-phrase  "from  flies  and  filth  to 
food  and  fever."  The  conveyance  of  fecal  matter  on  the 
feet  of  flies  has  been  clearly  demonstrated.  The  amount 
of  infection  by  this  means  varies  according  to  circumstances. 
In  a  well-sewered,  clean  community  where  the  excreta  of 
the  sick  are  properly  disinfected,  comparatively  few  cases 
could  be  due  to  fly  transmission.  On  the  other  hand  a 
maximum  of  fly  infection  is  reached  where  excreta  are 
improperly  disposed  of,  flies  swarm,  and  food  is  exposed. 


COMMUNICABLE    DISEASE 


191 


Such  conditions  obtained  in  the  United  States  Army  camps 
in  the  Spanish-American  war,  when,  it  is  estimated  by  the 
army  medical  authorities,  15  per  cent  of  the  numerous 
cases  were  due  to  fly  transmission. 

5.  Shellfish.  —  Oysters  and  other  shellfish  grown  (or, 
in  the  case  of  oysters,  "floated"  for  fattening  purposes) 
in  polluted  waters  may  convey  typhoid  infection.^  The 
typical  example  is  the  epidemic  at  Wesleyan  University, 
Middletown,  Conn.,  in  1894,  where  25  (one-quarter)  of 
those  who  attended  banquets  where  infected  oysters  were 
served  on  the  half-shell  developed  typhoid. 

6.  Raw  Vegetables  and  Fruits,  and  Other  Foods. 
—  Vegetables  may  become  infected  through  fertilization 
with  fresh  night-soil  or  sewage.  This  mode  of  transmis- 
sion is  not  very  common,  but  infection  has  been  traced  to 
water-cress  grown  in  polluted  water,  and  sporadic  cases 
similarly  arising  unquestionably  occur.  Other  foods  (e.g., 
fruits,  bread,  cake,  candy,  etc.)  subject  to  handling  or 
other  mode  of  infection,  and  eaten  raw,  may  also  convey 
the  infection. 

The  following  diagrammatic  representation  of  the  modes 
of  spread  of  typhoid  fever  is  adapted  from  Stiles  and 
Lumsden : 

Fingers  (direct  or  in- 
fecting food) 
Flies  (infecting  food) 
Water 


Excreta  from 


Typhoid 
patients 
or 

Typhoid 
germ 
carriers 


to 


Foods 


Mouths 
!-  to  -1      of 

persons 


Milk  (and  milk 
products) 

Shellfish  (oys- 
ters, etc.) 

Vegetables, 
fruits,  and 
other  foods 
eaten  raw 

^  Pease,  "  Relation  of  Oysters  to  the  Transmission  of  Infectious 
Diseases,"  Trans.  XV  Internal.  Co7igress  Hyg.  and  Demogr.,  1912, 
vol.  IV,  pt.  I. 


192  A  MANUAL   FOR   HEALTH  OFFICERS 

In  general,  water,  milk,  and  contact  infection  are  most 
common;  transmission  by  flies,  by  shellfish,  and  by  other 
foods  eaten  raw  is  less  common,  but  still  to  be  considered. 
Other  and  minor  modes  —  e.g.,  by  soiled  linen  and  other 
"fomites"  —  suggest  themselves.  The  importance  of  con- 
tact infection  of  the  various  kinds  has  been  on  the  whole 
overlooked,  though  it  has  been  emphasized  in  the  catch- 
phrases  "flies,  fingers  and  food"  (Sedgwick),  "dirt,  diar- 
rhoea and  dinner"  (Chapin). 

Contact  infection  is  of  particular  importance  in  connec- 
tion with  what  is  known  as  residual  typhoid.  The  term  is 
applied  to  the  unexplained  typhoid  fever  which  still  re- 
mains in  a  community  having  a  pure  or  purified  water- 
supply  and  in  which  all  definitely  known  sources  of  the 
disease  have  been  eliminated.  This  residual  typhoid  is 
spread  by  unseen  contact  infection,  frequently  from  un- 
recognized cases,  passing  directly  from  person  to  person  or 
indirectly  through  sporadic  infection  of  food  and  drink. 
This  simply  means  that  typhoid  fever,  like  a  number  of 
other  infections,  is  endemic  —  i.e.,  constantly  present. 
The  term  "prosodemic"  ("proceeding  through  the  popula- 
tion") has  been  suggested  in  this  connection  by  Sedgwick 
as  emphasizing  the  unrecognized  chain-like  paths  by  which 
the  disease  is  propagated.  The  term  "normal,"  meaning 
"usual,"  is  sometimes  applied  to  residual  typhoid,  but 
is  unfortunate  in  that  it  favors  tolerance  of  a  residual 
which  may,  through  popular  education  in  personal  hygiene 
and  through  care  on  the  part  of  health  authorities,  be  still 
further  reduced. 

Incidence.  —  Considering  its  preventability,  typhoid 
fever  occurs  to  an  undue  extent  in  the  United  States  as 
compared  with  other  civilized  countries.  In  the  Registra- 
tion Area  in  191 1  the  death-rate  was  21.0  per  100,000  popu- 
lation. Certain  individual  cities  ran  as  high  as  65,  while 
the  rates  for  others  were  under  5,  a  striking  demonstration 
of    the    fact    that    the   higher   mortalities   are   avoidable. 


COMMUNICAULI';    DISKASK  193 

McLaughlin  (quoted  by  Roscnau)  has  shown  that  in  1910 
there  was  an  excess  of  deaths  in  American  cities,  as  com- 
pared with  principal  European  cities,  of  18.5  per  100,000,  the 
contrasted  figures  being  6.5  and  25.0. 

The  greater  part  of  typhoid  mortality  falls  on  the  inidflle 
periods  of  life  (over  half  at  20-50  years,  maximum  specific 
death  rate  at  20-25). 

The  fatality,  or  case  mortality,  of  typhoid  fever  is  usu- 
ally taken  to  be  about  10  per  cent,  probably  somewhat 
less  if  the  mild  cases  detected  by  advanced  methods  are 
counted  in.  Conversely,  it  may  be  estimated  that,  on  the 
average,  for  each  typhoid  death  recorded  there  are  at  least 
ten  cases. 

The  seasonal  incidence  of  typhoid  fever  varies.  Where 
the  water-supply  is  typhoid-free,  the  greatest  number  of 
cases  occur  during  the  summer  months,  the  numbers  fol- 
lowing approximately  the  temperature  curve.  This  may 
be  explained  by  the  more  favorable  conditions  for  the 
germ  at  large,  by  fly-infection,  and  by  the  more  susceptible 
condition  of  the  gastro-intestinal  tract  in  warm  weather. 
On  the  other  hand,  if  the  water-supply  is  much  infected, 
there  occur  in  addition  to  the  summer  rise  irregular  rises 
at  various  times,  corresponding  to  the  amount  of  infection 
gaining  access  to  the  water,  currents  (in  lakes),  the  effects 
of  freshets  in  washing  infection  from  the  banks  of  streams 
and  bearing  it  rapidly,  and  other  such  factors. 

We  need  not  discuss  the  question  as  to  whether  typhoid 
fever  is  rather  a  rural  or  an  urban  disease.  It  is  both. 
While  urban  conditions  are  on  the  whole  more  favorable 
to  its  spread,  bad  conditions  as  to  disposal  of  excreta  in 
rural  districts  also  favor  infection.  While  the  actual 
amount  of  typhoid  in  the  country  districts  may  be  less,  it 
may  readily  be  communicated  to  city  dwellers  through  milk 
and  other  food  supplies  and  through  vacation  visits  to  un- 
sanitary farm  places.  Though  "vacation  typhoid"  has 
perhaps  too  often  been  made  the  theoretical  scapegoat  for 


194  A   iMANUAL   FOR   HEALTH  OFFICERS 

city  cases  occurring  in  the  fall  season,  it  has  nevertheless 
a  real  significance,  and  due  attention  should  be  paid  by 
vacationists  and  public  authorities  to  the  sewage  disposal 
and  water  supplies  of  farms  and  summer  resorts. 

In  mining  camps,  construction  camps,  and  primitive 
communities  where  there  is  improper  disposal  of  excreta, 
typhoid  fever  may  occur  heavily.  The  remedy  is  proper 
care  of  cases,  sanitary  privies  (sec  Chapter  VI),  and,  when 
need  be,  anti-typhoid  inoculation. 

In  dealing  with  typhoid  fever  statistics,  one  must  bear 
in  mind  the  possible  inaccuracy  of  diagnosis  (some  cases 
being  reported  as  "malaria"  or  the  improper  term  "typhoid 
malaria")  and  the  unfortunate  tendency  to  report  deaths  as 
due  to  mere  terminal  symptoms  —  e.g.,  pneumonia  —  in- 
stead of  the  disease  itself.  The  terms  which  are  still  occa- 
sionally met  with,  —  "intermittent  fever"  and  "remittent 
fever,"  used  as  practically  synonymous  with  typhoid, — 
should  never  be  used.  "Enteric,"  the  English  term  for 
"typhoid,"  is  sometimes  met  with. 

Protective  Inoculation.  —  There  is  no  specific  serum 
remedy  for  typhoid  fever.  Immunity  may,  however,  be 
conferred  by  a  process  similar  to  smallpox  vaccination. 
Killed  cultures  of  typhoid  bacilli  are  injected  at  intervals 
of  five  days  at  least  three  times,  whereby  the  subject 
develops  an  immunity.^  This  inoculation  should  be  taken 
by  all  who  nurse  typhoid  patients  or  are  otherwise  directly 
and  unavoidably  exposed.     Results  obtained  in  the  U.  S. 

'  The  technique,  however,  varies.  See  Rosenau,  "  Preventive 
Medicine  and  Hygiene,"  1913,  p.  94.  Also:  Hachtel  and  Stoner, 
"  The  Use  of  Anti-Typhoid  Vaccine  in  Public  Institutions  and  Among 
Civilians,"  Am.  Jour.  Pub.  Health,  1912,  vol.  II,  no.  3,  p.  157;  Force, 
"  Institutional  Vaccination  Against  Typhoid  Fever,"  Am.  Jour.  Pub. 
Health,  1913,  vol.  Ill,  no.  8,  p.  750;  Spooner's  and  Goltman's  ac- 
counts of  their  experiences  with  anti-typhoid  inoculation  among  nurses 
and  the  public  in  Trans.  XV  Internal.  Congress  Hyg.  and  Demogr., 
1912,  vol.  IV,  pt.  I ;  and  a  summary  of  the  subject  by  Townsend  in  Am. 
Jour.  Pub.  Health,  1914,  vol.  IV,  no.  11,  p.  993. 


COMMUNICABLE   DISEASE  195 

Army  have  clearly  demonstrated  its  high  efficacy.  In  an 
encampment  at  San  Antonio,  Texas,  during  four  months 
ending  July  10,  1911,  among  12,801  men  inoculated  no 
typhoid  fever  d(;veloped.  The  only  two  cases  which  oc- 
curred in  the  encampment  were  those  of  a  teamster  who 
had  not  been  inoculated  and  of  a  hospital  corps  man 
who  had  not  completed  the  required  inoculations.  During 
the  same  period  considerable  typhoid  fever  occurred  in  the 
civil  population  in  the  neighborhood.  The  record  of  these 
troops  contrasts  markedly  with  that  of  the  Spanish-American 
War,  when  one-fifth  of  the  troops  developed  the  disease. 

It  is  advisable  that  persons  who  take  the  typhoid  fever 
inoculation  be  in  good  health,  for  the  process  apparently 
has  some  tendency  to  revive  old  chronic  affections  (e.g., 
tuberculosis)  and  cause  them  to  become  acute.  Instances 
of  this  tendency  are,  however,  infrequent,  and  do  not 
constitute  a  serious  drawback  in  the  use  of  this  valuable 
prophylactic  measure. 

CONTROL 

Sedgwick  has  epitomized  typhoid  prevention  in  the 
dictum  that  the  problem  is  "to  keep  the  excreta  of  A  out 
of  the  mouth  of  B."  In  this  definite  sense  typhoid  fever 
is  a  filth  disease.  The  dictum  refers  not  only  to  the  known 
case  but  also  to  the  disposal  of  all  excreta  and  sewage,  for 
all  must  be  considered  as,  potentially  at  least,  infected. 
The  same  authority  has  further  said  that  "every  case  of 
typhoid  fever  comes  from  somebody's  ignorance  or  neg- 
lect." The  statement  certainly  applies  to  all  recognized 
typhoid  cases  and  carriers;  as  for  the  undetected  cases  and 
carriers,  they  constitute  a  separate  and  distinct  problem 
which  will  be  taken  up  presently. 

The  following  measures  should  be  carried  out  by  the 
health  authorities: 

I.  Registration  of  Cases.  —  Physicians  should  be  re- 
quired to  report  typhoid  fever  precisely  as  diphtheria  or 


196  A  MANUAL   FOR   HEALTH  OFFICERS 

any  other  acute  communicable  disease.  Histories  of  the 
cases  should  be  regularly  taken  and  studied. 

The  local  health  authorities  should  make  provision  for 
ready  bacteriological  diagnosis,  either  locally  or  by  a  state 
laboratory.  This  is  of  great  importance  not  only  in  the 
treatment  of  the  case  but  also  in  the  protection  of  the  com- 
munity. The  most  effective  method  for  early  diagnosis 
is  by  blood  cultures.  According  to  this  method  a  small 
quantity  of  blood  is  drawn  and  incubated  by  a  special 
method  which  shows  up  the  typhoid  bacillus  if  present  in 
any  considerable  numbers.  Since  the  bacilli  appear  in 
the  blood  early  in  the  disease,  the  diagnosis  may  thus  be 
promptly  established.  Later  in  the  course  of  the  disease 
the  blood  serum  has  the  property  of  causing  agglutination 
(clumping)  of  typhoid  bacilli,  giving  what  is  known  as  the 
Widal  reaction,  which  is  frequently  used  as  a  diagnostic  test. 
In  this  test  one  or  two  drops  of  the  blood  may,  if  necessary, 
be  dried  and  sent  to  a  distance  for  examination.  The 
method  is  simple,  prompt  and  easy,  but  of  little  or  no  value 
in  early  stages  of  the  disease.  The  reaction  does,  however, 
persist  after  recovery,  and  may  therefore  determine  that 
suspected  persons  have  had  typhoid  fever  or  are  carriers.^ 
In  comparing  the  blood  culture  method  with  the  serum 
reaction  method  it  should  be  remembered  that  the  bacilli 
are  present  in  the  blood  throughout  the  whole  course  of  the 
fever,  and  may  be  detected  in  a  large  proportion  of  the 
cases,  whereas  the  Widal  reaction  may  not  be  constantly 
present  even  after  the  second  week  and  may  therefore 
more  readily  be  missed.  Hence  for  a  complete  diagnosis 
of  an  obscure  case  by  the  latter  method  the  tests  should, 
if  negative,  be  repeated  daily  for  some  days.  The  feces 
and  urine  may  also  be  examined  for  the  presence  of  the 
bacilli  (see  below). 

In  connection  with  the  blood  tests  it  should  be  remem- 

Mt  is  important  to  note  that  persons  who  have  had  the  protective 
typhoid  inoculation  also  carry  a  positive  Widal  reaction. 


COMMUNICAHI.I':    DISKASE  I97 

bcred  that  the  meLhods  arc  no!  infallihlc  aiul  ihal  one 
negative  result  is  not  conclusive.  In  case  of  doubt  as  to 
clinical  symptoms,  while  further  tests  are  being  awaited, 
the  case  should  be  regarded  as  possible  typhoid  and  pre- 
cautions taken  accordingly. 

2.  Isolation  and  Disinfection.  — -  Since  typhoid  fever  is 
truly  communicable  by  contact,  cases  should  be  isolated 
and  the  feces  and  urine  should  be  carefully  disinfected.^ 
The  sick-room,  but  not  necessarily  the  house,  should  be 
placarded.  If,  under  satisfactory  conditions,  visitors  are 
admitted,    they    should    not    touch    anything    and    should 

'  See  methods,  p.  582  ff.  The  following  procedure  has  been  adopted 
in  the  rural  districts  on  the  water-sheds  of  Baltimore: 

"  Special  disinfecting  outfits  are  distributed  to  the  homes  of  the 
patients  by  an  inspector  and  full,  printed  directions  for  their  use  are 
left.  The  attending  physician,  nurse  or  attendant  is  also  furnished 
with  a  copy  of  instructions.  An  inspector  carries  a  '  standard  package  ' 
of  disinfecting  appliances  to  the  house,  unpacks  it,  makes  up  solutions 
and  explains  their  use.  Enough  disinfectant  is  left  for  4  weeks.  After 
recovery  of  the  patient  the  inspector  removes  the  appliances,  which 
may  be  used  again.  The  outfit  consists  of:  2  five-gallon  buckets, 
phenol  (90  per  cent),  urinal,  enamel  basin,  corrosive  sublimate  tablets, 
bed-pan,  enamel  measure,  lactose  bile  outfit,  mosquito  netting  canopy. 
Directions  for  the  use  of  the  outfit  are  very  full  and  plain,  including 
instructions  to  physician,  attendants  and  inspectors,  and  a  copy  of  the 
law  applying  to  these  cases.     [  Cf.  methods,  p.  582  fT.] 

"  When  disinfection  of  stools  is  about  to  be  discontinued  a  specimen 
of  the  stools  is  sent  in  the  bile  tube  provided  to  the  laboratory,  where  it 
is  examined  for  typhoid  bacilli.  It  is  required  that  stools  of  a  convales- 
cent be  disinfected  until  the  typhoid  bacillus  is  no  longer  present.  .  .  . 
It  is  the  authors'  belief  that  negative  cultures  should  be  required  of 
typhoid  cases  just  as  much  as  of  diphtheria  cases.  By  careful  disin- 
fection and  examination  until  negative  cultures  are  obtained,  they 
believe  that  the  starting  point  of  what  might  be,  otherwise,  many  cases 
of  typhoid  fever  can  be  removed,  and  that  this  is  the  most  important 
source  at  which  to  attack  the  spread  of  typhoid  throughout  the  com- 
munity." (Price,  Stokes,  and  Rohrer,  quoted  in  Am.  Jour.  Pub. 
Health,  1912,  vol.  II,  no.  i,  p.  64.)  Cf.  Grandy  and  Andrews,  "  Munic- 
ipal Control  of  Typhoid  Fever,"  Am.  Jour.  Pub.  Health,  1913,  vol.  Ill, 
no.  8,  p.  746. 


198  A  MANUAL   FOR  HEALTH  OFFICERS 

wash  and  disinfect  their  hands  if  they  do  so;  pains  should 
be  taken  to  impress  people  with  the  fact  that  the  disease 
is  truly  contagious.  In  no  case  should  children  be  per- 
mitted in  the  sick-room.  If  satisfactory  isolation  and  dis- 
infection of  discharges  cannot  be  secured,  the  patient  should 
go  to  the  hospital;  only  thus  can  secondary  contact  cases 
be  avoided. 

The  isolatio7i  should  not  be  terminated  until  the  patient  has 
ceased  to  shed  the  germs  in  feces  and  urine.  The  patient  com- 
monly becomes  free  from  infection  during  convalescence, 
but  in  the  carrier  cases  the  shedding  of  germs  continues 
for  a  greater  or  less  time  afterwards.  Discontinuance  of 
the  germs  can  be  determined  only  by  cultural  examination. 
Rosenau  recommends  four  consecutive  negative  examina- 
tions of  feces  and  urine,  but  more  practicable  is  the  rule 
that  no  convalescent  be  released : 

until  two  consecutive  negative  examinations  have  been  made  of  the 
stools  and  urine.  If  the  patient's  business  brings  him  in  contact  with 
food  supplies,  four  consecutive  negative  examinations  of  the  stools  and 
urine  should  be  required.  In  case  a  person  is  found  to  be,  in  spite  of  all 
treatment,  a  chronic  carrier  of  typhoid  bacilli,  he  should  be  kept  under 
competent  supervision  by  the  local  board  of  health;  he  should  not  be 
allowed  to  engage  in  occupations  requiring  the  handling  of  foodstuffs, 
and,  in  case  he  moves  to  another  neighborhood,  the  local  health  author- 
ities of  that  neighborhood  should  be  notified  at  once.' 

Even  so,  while  a  negative  result  from  the  urine  is  of  the 
greatest  possible  value,  a  negative  result  from  the  stools 
is  of  practically  no  value  for  the  reason  that  the  excretion 
by  the  latter  channel  is  very  frequently  intermittent. 
Hence  some  authorities  even  recommend  examination  of 
feces  monthly  for  one  year  for  all  convalescents.  This 
consideration  of  intermittency  emphasizes  the  possible 
dangers  from  every  typhoid  convalescent  and  the  necessity 
of  instructing  such  persons  to  exercise  scrupulous  personal 

'  Pamphlet  of  the  Massachusetts  State  Board  of  Health  on  the  con- 
trol of  typhoid  fever. 


COMMUNICAI'.IJC    DISIOASIO  igp 

cleanliness. "^  The  freciuciicy  of  ci)i(l('mics  traced  to  carriers 
bears  out  this  statement  concretely. 

No  true  cure  for  fecal  typhoid  carriers  is  known.  The 
administration  of  urotropine,  a  urinary  disinfectant,  may, 
however,  be  employed  to  rid  the  urine  of  germs  in  con- 
valescence.    (For  further  remarks  on  carriers,  see  below.) 

In  comparison  with  the  present  generally  lax  practice  in 
relation  to  control  of  the  individual  case  of  typhoid  fever, 
the  measures  just  described  will  perhaps  at  first  sight 
appear  impracticable.  They  are,  however,  based  upon 
the  best  indications  of  the  preventive  medicine  of  typhoid 
fever.  When  the  strict  measures  which  in  the  past  have 
been  applied  to  diphtheria,  scarlet  fever,  and  other  con- 
tagious diseases  are  considered,  it  would  certainly  seem  that 
the  same  kind  of  measures  should  be  accepted  when  indi- 
cated (as  they  are)  as  necessary  for  the  efTective  attack 
on  this  no  less  serious  public  health  problem.  The  local 
health  officer  should  therefore  carry  them  out  to  the  great- 
est possible  extent  that  cooperation  of  the  public  and  of  the 
medical  profession  will  permit. 

3.  General  Protection  of  Water  and  Food  Supplies.  — 
The  prevention  of  the  pollution  and  infection  of  water 
and  food  supplies  (especially  milk)  is  a  large  and  important 
part  of  the  defence  against  typhoid  fever.  These  subjects 
are  treated  in  detail  in  Chapters  III  and  IV. 

4.  Popular  Education.  —  Much  can  be  done  through 
publicity  as  to  the  methods  of  prevention,  particularly  upon 
the  following  points:  avoidance  of  suspicious  sources  of 
water  and  food,  especially  in  traveling  or  on  vacations  in 
rural  districts;  boiling  of  suspicious  drinking  water;  home 
pasteurization  of  milk  not  so  treated  by  the  dealer;  abate- 
ment of  fly-breeding  places  and  protection  of  foods  from 
flies;  general  cleanliness,  personal,  domestic,  and  munici- 
pal ;  the  contagious  nature  of  typhoid  fever ;  and  the  neces- 
sity for  strict  municipal  control. 

^  Richardson,  "  Dirty  Hands  and  Typhoid  Fever,"  see  p.  116. 


200  A   MANUAL    IX)R   HE.\LTH   OFFICERS 

5.  Typhoid  Vaccine.  —  Health  authorities  should  en- 
courage the  use  of  protective  inoculations  for  those  who 
nurse  typhoid  patients  and  for  others  (e.g.,  travelers  and 
vacationists)  who  may  be  exposed,  and  sliould  be  prepared 
to  furnish  a  reliable  vaccine  free  or  at  cost.  But  the  use  of 
typhoid  inoculation  as  a  general  protective  measure  among 
the  public  at  large  is  not  feasible. 

6.  Carriers.  —  "In  about  4  per  cent  of  all  cases  of 
typhoid  fever  the  patient  continues  to  shed  typhoid  bacilli 
in  the  urine  or  feces  during  and  after  convalescence" 
(Rosenau).^  Such  carriers  may  be  called  acute  or  chronic, 
according  to  whether  they  harbor  the  bacilli  for  a  shorter 
or  longer  time.  There  are  also  "temporary"  carriers  who 
have  never  shown  clinical  symptoms  but  who  nevertheless 
harbor  and  excrete  bacilli.  Negative  statements,  how- 
ever, as  to  their  clinical  history,  on  the  part  of  suspected 
persons,  should  be  sceptically  received;  not  infrequently 
past  illness,  especially  if  slight,  is  forgotten  or  concealed. 

In  all  these  instances  typical  typhoid  fever  may  be 
communicated  by  the  carrier  to  well  persons.  It  has  been 
estimated  that  one  person  in  every  thousand  of  the  general 
population  is  a  carrier  (Albert). 

We  have  already  alfudcd  in  brief  (section  (2)  above)  to 
the  detection  and  control  of  carriers  after  convalescence. 

In  a  search  for  carriers  (e.g.,  at  a  dairy)  Widal  tests  may 
be  made  of  all  suspected  persons.  Those  who  show  a 
positive  or  doubtful  Widal  should  then  be  subjected  to 
bacteriological  examination  of  stools  and  urine.  In  col- 
lecting samples  for  this  purpose,  the  sanitary  officer  must 
be  assured  that  the  specimens  actually  are  derived  from  the 
persons  in  question,  for  there  may  be  deception  on  the  part 

'  See  also  p.  109  of  present  volume.  Richardson  {Am.  Jour.  Pub. 
Health,  19 14,  vol.  IV,  no.  2)  states  that  women  carriers  are  five  times 
as  numerous  as  men  and  calls  attention  to  the  fact  that  women  are  more 
frequently  employed  in  the  handling  of  foods.  He  states  that  urinary 
carriers  are  more  dangerous  than  fecal  carriers.  The  latter,  however, 
being  intermittent,  may  escape  detection. 


COMMUNICABFJ':    DISEASE  20I 

of  persons  who  suspect  that  they  may  harbor  the  bacillus. 
It  should  also  be  remembered  that  carriers  are  frequently 
intermittent  and  that  a  single  negative  result  in  stools 
is  not  conclusive.  If  a  person  is  particularly  suspected 
the  examination  should  be  repeated  twice  or  more. 
By  the  use  of  tact,  specimens  for  these  examinations 
can  usually  be  obtained.  If,  however,  persons  refuse,  the 
health  authorities  should  have  power  to  restrain  them 
until  the  examinations  are  permitted. 

There  are  a  number  of  examples  on  record  of  epidemics 
caused  by  carriers.  "Typhoid  Mary,"  the  cook  who  dis- 
tributed infection  through  a  number  of  families  by  whom 
she  was  employed,  is  one  of  the  best  known  examples.  In 
New  York  City,  in  1909,  an  epidemic  of  380  cases  was 
traced  to  a  dairyman  who  was  a  typhoid  bacillus-carrier 
of  46  years  standing,  thus  illustrating  the  danger  even 
from  old  cases  (cf .  page  284) . 

The  administrative  control  of  carriers  is  a  vexed  question. 
Persons  who  have  had  typhoid  fever  should  certainly  not 
be  permitted  to  engage  in  the  preparation  or  handling  of 
foods  eaten  raw,  particularly  milk  and  milk-products, 
until  their  freedom  from  infection  has  been  thoroughly 
established  (see  (2)  above).  Detected  carriers  cannot 
practicably  be  isolated,  but  should  be  kept  under  strict 
surveillance.  No  effective  means  of  curing  carriers  is  at 
present  known.  The  urine  of  urinary  carriers  may  be 
disinfected  with  urotropine,  but  no  treatment  is  available 
for  the  class  of  fecal  carriers.  The  surveillance  of  carriers 
should  include  forbidding  employment  in  any  occupation 
in  which  foods  eaten  raw  are  prepared  or  handled;  this 
would  bar  out  the  milk  industry,  cooking,  baking,  con- 
fectionery and  ice-cream  making,  nursing,  etc.  The 
whereabouts  and  occupation  of  the  carrier  should  be  con- 
stantly known  to  the  health  authorities,  and  periodic  ex- 
aminations of  excreta  should  be  made  until  a  satisfactory 
number    of    consecutive    negatives    are    obtained.     Some 


202  A   MANUAL   FOR   HEALTH   OFFICERS 

authorities  recommend  such  examinations  monthly  for 
one  year  for  all  typhoid  convalescents.  Extreme  measures 
will  have  to  be  taken  in  order  effectively  to  cope  with  the 
carrier  problem. 

Carriers  should  be  instructed  as  to  the  danger  to  others, 
and  should  carry  out  carefully  instructions  as  to  the  cleans- 
ing and  disinfection  of  their  hands  (page  584). 

The  existence,  at  large,  of  unrecognized  carriers  lends 
special  weight  to  all  measures  for  simple  but  scrupulous 
cleanliness  on  the  part  of  all  persons  who  handle  foods 
which  may  act  as  vehicles  of  infection,  also  to  the  general 
protection  afforded  by  pasteurization  of  milk-supplies. 
The  importance  of  the  carrier  problem  in  typhoid  fever 
can  scarcely  be  overemphasized ;  upon  its  solution  depends 
very  largely  the  elimination  of  the  mass,  already  referred 
to,  of  "residual"  typhoid.^ 

Paratyphoid  Fever.  —  Paratyphoid  fever  is  caused  by 
the  paratyphoid  bacillus,  which  is  similar  to  the  typhoid 
organism  but  distinguishable  from  it  by  laboratory  tests. 
Clinically,  also,  the  disease  is  similar  to  typhoid,  and  fre- 
quently can  only  be  distinguished  from  it  by  bacteriologi- 
cal examination.  Many  of  the  cases  are  doubtless  reported 
as  typhoid  fever.  As  in  typhoid  fever,  the  germ  enters  the 
body  by  way  of  the  mouth  and  alimentary  tract  and  is 
shed  oft'  in  the  intestinal  discharges. 

Paratyphoid  fever  does  not  occur  as  frequently  as  typhoid 
and  rarely  causes  conspicuous  epidemics.  A  peculiar 
property  of  the  bacillus  is  its  faculty  for  growing  in  meat, 
infecting  the  mass  without  affecting  it  in  appearance, 
flavor,  or  odor  (see  page  400  f.).  This  fact  argues  strongly 
for  aseptic  inethods  of  cleanliness,  for  thorough  cooking  of 
meat,  and  for  protection  of  it  before  eating.  Otherwise 
prevention  is  the  same  as  for  typhoid  fever:  isolation  of 
cases  and  disinfection  of  discharges,  protection  of  water 
and  food  supplies,  avoidance  of  fl>'  infection,  etc. 
1  Cf.  also  p.  108  ff. 


COMMUNFCAUIJC    DISEASE  203 

REFERENCES 

Whipple,  "  Typhoifl  Fever,"  John  Wiley  and  Sons,  Inc.,  1908. 

Bolduan,  "  Ty])hoi(l  Fever  in  New  York  City,  toj^ethcr  with  a  Dis- 
cussion of  the  Methods  found  Serviceable  in  Studying  its  Occurrence," 
Am.  Jour.  Pub.  Health,  1912,  vol.  II,  nos.  5  (p.  339),  6  (p.  431),  7  (p.  538). 
(Some  of  the  principles  suggested  are  applicable  to  typhoid  fever  study 
in  small  cities). 

The  Bulletins  of  the  Hygienic  Laboratory,  U.  S.  Public  Health  Ser- 
vice, on  "Typhoid  Fever  in  the  District  of  Columbia"  (1907  fif.)  illus- 
trate expert  investigation  methods  and  contain  valuable  data. 


CHOLERA 

Cholera  (more  accurately  Asiatic  cholera,  to  distinguish 
it  from  other  cholera-like  diseases)  is  spread  in  very  much 
the  same  way  as  typhoid  fever.  It  is  caused  by  the  Vibrio 
cholera  ("comma-bacillus,"  from  its  shape),  which  enters 
the  system  by  way  of  the  mouth  and  leaves  it  in  the  bowel 
discharges  (occasionally  in  the  vomitus;  not,  however,  in 
the  urine).  The  vibrios  may  be  detected  in  the  discharges 
by  bacteriological  examination. 

The  measures  of  prevention  are  in  principle  the  same  as 
for  typhoid  fever.  It  is  "contagious"  in  the  same  sense 
that  typhoid  fever  is  contagious,  and  strict  disinfection  of 
discharges,  body  and  bed  linen  and  other  articles  must  be 
practised.  Cases  should  be  treated  in  a  special  hospital 
and  should  not  be  released  until  two  successive  examina- 
tions of  the  stools  at  5-day  intervals  have  proved  negative. 
In  epidemics  cholera  carriers  exist.  Immunity  from  cholera 
may  be  obtained  by  an  inoculation  similar  in  principle  to 
the  protective  typhoid  inoculation,  which  should  be  applied 
to  nurses,  physicians,  and  other  persons  exposed. 

Since  at  the  present  time  there  is  no  cholera  in  the  United 
States,  the  principal  line  of  defence  is  the  maritime  quar- 
antine, which  maintains  certain  regulations  for  detention 
and  examination  of  suspects  that  need  not  be  detailed 
here. 


204  A   MANUAL    I'OR   HEALTH   OFFICERS 

DYSENTERIC   DISEASES 

Under  this  head  we  may  group  a  numl)cr  of  communicable 
diseases  characterized  by  dysentery  or  diarrha?a  of  known  or 
unknown  cause.  These  diseases  are  all  communicable  in 
the  same  way  as  typhoid  fever,  and  prevention  demands 
isolation  with  disinfection  of  bowel  discharges,  and  avoid- 
ance of  contact,  water,  food,  and  fly  transmission.  To 
determine  the  cause  in  any  case,  laboratory  examination 
of  stools  is  required,  though  practically  this  may  not  be 
necessary.     Carriers  may  be  more  or  less  numerous. 

First,  there  is  bacillary  dysentery,  caused  by  types  of 
the  Bacillus  dysenterm,  which  is  closely  related  to  the  ty- 
phoid organism.  The  disease  is  truly  epidemic  in  char- 
acter, and  may  be  spread  in  the  same  manner  as  typhoid 
fever,  but  it  is  not  so  extensive  in  distribution.  It  has 
frequently  been  noted  in  insanitary  ships,  jails,  etc. 

Again,  there  is  a  dysentery  due  to  a  protozoon  parasite, 
Entamceha  hystolytica,  known  as  amoebic  dysentery.  It  is 
chiefly  a  tropical  disease.  Although  it  does  not  occur  in 
epidemics,  it  is  spread  in  much  the  same  ways  as  typhoid 
fever. 

Finally,  there  are  various  dysenteries  and  diarrhoeas  of 
obscure  causation,  but  communicable.  Infants  in  partic- 
ular are  affected  by  intestinal  diseases  or  disorders  which 
are  infectious  and  in  some  cases  communicable.  These  are 
sometimes  known  by  the  indefinite  titles  "infantile  cholera," 
"cholera  nostras,"  "winter  cholera,"  "summer  complaint," 
etc.  Such  terms  are  unsatisfactory  as  being  obscure  and 
signifying  no  more  than  diarrhoea  or  enteritis,  which  may 
be  communicable  or  may  be  merely  symptomatic.  Cer- 
tain investigations  have  indicated  that  some  forms  of 
diarrhoea  and  enteritis  in  infants  are  communicable,  and 
therefore  infantile  diarrha'a  should  he  made  reportable  and 
isolation  and  special  cleanliness  should  be  observed  in  such 
cases.     In  many  cases  of  infant  diarrhoea  the  condition 


COMMUNICABLE    DISEASE  205 

is  induced  l)y  improper  feeding  or  clolhinj^  or  unhygienic 
practices;    all  of  which  will  be  discussed  in  Chapter  II. 

Diarrhceal  disease  in  the  general  population  is  frequently 
water-borne,  and  the  occurrence  of  unusual  numbers  of 
cases  of  diarrhoea  should  raise  a  suspicion  of  the  public 
water-supply.  (Sec  remarks  under  water  transmission  of 
typhoid  fever.)  Under  such  circumstances  there  may  also 
occur  secondary  cases  produced  by  contact  infection,  as 
well  as  numerous  carriers. 

Control.  —  Health  authorities  should  require  the  same 
measures  for  diarrhoeal  diseases  as  for  typhoid  fever:  re- 
porting; isolation  (or  at  least  measures  of  cleanliness  and 
disinfection) ;  and  should  arrange  for  laboratory  examina- 
tions when  desired  by  the  physician. 

HOOKWORM   DISEASE 

Hookworm  disease  (uncinariasis  or  anchylostomiasis)  is 
due  to  infection  of  the  intestine  with  a  small  worm  which 
produces  anaemia,  emaciation,  loss  of  strength  and  ambi- 
tion, and  other  forms  of  vital  depression.  Hence  the  name 
"miners'  anaemia"  and  other  similar  designations  of  it. 
The  disease  is  not  only  a  seriously  debilitating  one  in  itself, 
but  also  strongly  predisposes  to  tuberculosis  and  other 
infections.  The  eggs  of  the  worm  are  shed  ofif  in  the  bowel 
discharges.  The  disease  is  chronic  in  character,  the  victims 
usually  going  about  their  usual  occupations  and  frequently 
having  no  knowledge  of  their  disease. 

The  problem  of  hookworm  disease  is  largely  one  of  soil 
pollution.  While  it  may  be  transmitted  by  contact, 
polluted  water,  or  polluted  food,  the  entrance  atrium  being 
in  these  cases  the  mouth,  the  great  majority  of  cases  are 
contracted  in  the  following  way.  The  eggs  shed  by  the 
hookworm  victim  hatch  into  larvae,  w^hich  infect  the  soil. 
These  larvae  get  upon  the  skin  of  the  hands  of  persons 
touching  the  soil  or  of  the  feet  of  persons  walking  bare- 
foot upon  it.     As  soon  as  the  larvae  touch  the  skin  they 


2o6  A  MANUAI.   I'OR   HEALTH  OFFICERS 

make  their  way  through  it,  and  then,  by  a  roundabout 
route  which  need  not  be  described  here,  to  the  small  in- 
testine. There  they  develop  into  adult  worms,  cling  to  the 
mucous  membrane,  and  produce  eggs  which,  as  already 
remarked,  pass  oflF  in  the  bowel  discharges.  The  passage 
of  the  lar\^?e  through  the  skin  is  attended  with  an  inflam- 
matory irritation  which  gives  rise  to  the  name  "ground- 
itch"  for  this  stage  of  the  disease. 

In  the  South  (as  in  many  tropical  and  subtropical  coun- 
tries), where  improper  disposal  of  excreta  frequently  pre- 
vails, where  the  temperature  is  favorable  to  the  parasite, 
and  where  persons  frequently  go  barefoot,  hookworm  dis- 
ease is  a  very  serious  problem.  Farther  north,  where  these 
conditions  are  not  so  prevalent,  it  is  not  endemic;  the  fact 
that  freezing  kills  the  larvae  also  tends  to  natural  prevention 
in  the  Northern  United  States. 

Control.  —  The  chief  measure  against  hookworm  disease 
is  prevention  of  soil  pollution.  This  requires  the  extension 
of  sewers  and  the  use  of  proper  privies  in  unsewered  villages 
and  country  districts.  The  promiscuous  and  improper 
disposal  of  excreta  in  any  other  manner  must  be  strictly 
prohibited.  Personal  prophylaxis  through  cleanliness, 
avoidance  of  contact  with  polluted  soil,  avoidance  of  pol- 
luted water  and  foods,  and  boiling  of  water  from  suspi- 
cious sources,  goes  without  saying.  Popular  enlightenment, 
followed  up  by  rigid  administration  of  sanitary  regulations, 
is  necessary  for  thorough  eradication. 

Infected  persons  may  readily  be  cured  by  administration 
of  thymol  or  other  suitable  vermifuge. 

III.   DISEASES    SPREAD    BY    INSECTS    AND 
VERMIN 

In  this  section  we  shall  consider  chiefly:  malaria  and 
yellow  fever,  transmitted  through  the  bites  of  definite 
species  of  the  mosquito;  poliomyelitis  (infantile  paralysis), 
transmitted  through  the  bite  of  the  stable  fly;    various 


COMMUNTCABT.E   DISEASE  207 

diseases  (e.g.,  typhoid  fever)  conveyed  mechanically  by  the 
common  house-fly;  and  plague,  transmitted  through  the 
bite  of  the  flea.' 

MOSQUITO-BORNE   DISEASES 
MALARIA 

The  parasite  (plasmodium)  of  malaria  is  conveyed  from 
man  to  man  by  the  genus  Anopheles  mosquito,  and  by  no 
other  means.  The  microorganism  goes  through  certain 
parts  of  its  life-cycle  in  man  and  through  others  in  the 
mosquito,  which  is  known  as  the  intermediary  host.  It 
is  acquired  by  the  mosquito  through  biting  the  malaria 
patient,  and  is  likewise  transmitted  to  a  new  victim,  after 
a  sufficient  number  of  days  (about  twelve)  has  elapsed  for 
its  development  in  the  insect,  through  the  bite  of  the  in- 
fected mosquito.  Several  different  varieties  of  malaria 
are  known,  caused  by  distinct  microorganisms;  these  are 
known  as  quartan  fever,  tertian  fever,  and  estivo-autumnal 
or  tropical  malaria,  the  first  two  of  these  names  being  de- 
rived from  the  number  of  days'  interval  at  which  the  at- 
tacks recur.     Carriers  are  thought  to  exist. 

The  distribution  of  the  malarial  mosquito  and  of  the 
disease  is  irregular,  but  the  disease  occurs  most  frequently 
in  southern  and  tropical  climates  where  there  are  swamps 
and  other  accumulations  of  stagnant  water  and  where  a 
long  warm  season  favors  mosquito-breeding.  While  some 
regions  are  malaria-free,  in  others  the  disease  constitutes  a 
very  serious  problem.  In  191 1,  1802  deaths  were  ascribed 
to  malaria  in  the  Registration  Area.  In  addition  to  the 
actual  mortality  there  is  great  damage  in  the  general  de- 
bility (cachexia)  characteristic  of  the  chronic  state  of  the 
disease. 

1  For  fly  and  mosquito  suppression  see  Chap.  VI.  For  fuller  treat- 
ment of  the  subject  of  insects  and  disease  see  Rosenau,  "  Preventive 
Medicine  and  Hygiene,"  Doane,  "  Insects  and  Disease,"  and  other  sim- 
ilar works.     Cf.  references,  pp.  468,  474  f. 


208  A  MANUAL  FOR  HEALTH  OFFICERS 

In  malarial  regions  safety  for  the  individual  may  be 
secured  by  living  in  screened  houses  and  by  protection 
against  the  bites  of  mosquitoes  when  out  during  the  day. 
Where  such  protection  is  not  feasible,  prophylactic  immu- 
nity may  be  secured  by  repeated  doses  of  quinine.  But 
these  are  only  personal  measures,  inconvenient  at  the  best, 
and  in  populated  regions  cannot  take  the  place  of  general 
public  measures. 

Control.  —  The  administrative  measures  for  the  control 
of  malaria  are: 

1.  Registration  of  cases,  which  is  furthered  by  affording 
facilities  for  diagnosis  through  blood  examination. 

2.  Effective  screening  of  the  patient  against  mosquitoes. 
Destruction  of  infected  insects. 

3.  Mosquito  suppression  (see  Chapter  VI). 

YELLOW  FEVER 

Yellow  fever  occurs  under  the  same  sort  of  circumstances 
as  malaria.  It  is  likewise  conveyed  through  the  bite  of  a 
mosquito,  the  causative  microorganism  being  unknown  but 
presumably  a  protozoon somewhat  related  to  that  of  malaria. 
Yellow  fever  is,  however,  transmitted  by  a  definite  and 
distinct  species  of  mosquito,  the  Aedes  (formerly  Stegomyia) 
calopus.  It  is  not  conveyed  by  fomites  —  e.g.,  clothing  — 
as  was  formerly  thought,  nor  by  any  other  means  than  the 
specific  species  of  mosquito.  The  parasite  requires  about 
twelve  days  for  its  development  in  the  mosquito,  and  the 
incubation  period  in  the  infected  person  is  from  two  to 
five  or  six  days.  "All  the  experimental  evidence  thus  far 
shows  that  the  infection  is  absent  from  the  blood  after 
the  third  day,  and  that  mosquitoes  do  not  become  infective 
after  this  period  "  (Rosenau). 

Control  is  much   the  same  as  for  malaria.^     There  is, 

*  Attention  is  called,  however,  by  Rosenau,  to  the  difference  in  amen- 
abiUty  to  control  between  the  two  diseases.  Malaria  is  more  difficult 
to  eradicate  because  the  breeding  places  of  the  Anopheles  mosquito  are 


COMMUNICABLE  DISEASK  209 

however,  no  bacteriological  method  of  diagnosis  and  greater 
precautions  should  therefore  be  taken  with  suspected  cases. 
The  radical  measure  is  of  course  mosquito  suppression. 

REFERENCES 

Ross,  "  The  Prevention  of  Malaria." 

Boyce,  "  Yellow  Fever  and  Its  Prevention." 

FLY-BORNE   DISEASES 

We  must  distinguish  two  modes  of  disease  transmission 
by  flies: 

(i)  Through  the  bite  of  the  stable  fly  (Stomoxys  calcitrans) 
the  virus  of  infantile  paralysis  (see  page  243)  may  be  trans- 
mitted. Anthrax  (page  250)  may  also  be  inoculated  into 
man  in  the  same  way. 

(2)  Acting  mechanically,  through  the  conveyance  of 
infected  matter  on  its  feet  and  proboscis,  the  common 
house-fly  may  carry  the  germs  of  typhoid  fever,  diphtheria, 
tuberculosis,  infantile  diarrhoea  and  enteritis,  and  other 
diseases.  The  ways  by  which  infectious  matter  may  be 
carried  from  privy-vaults  and  infectious  discharges  to  milk 
and  other  food,  infants'  nursing  bottles,  and  the  like,  have 
been  indicated  in  previous  pages  under  the  head  of  typhoid 
fever,  etc.,  and  need  not  be  elaborated  upon  here. 

While  the  amount  of  disease  conveyed  by  the  fly  is  not 
exactly  known,  it  is  quite  large  enough,  under  either  of 
the  above  heads,  to  justify  measures  of  fly  suppression. 
For  such  measures  see  Chapter  VI. 

more  widely  spread  and  difficult  to  detect  and  eliminate,  those  of  the 
Stegomyia  being  practically  confined  to  artificial  containers  in  the 
neighborhood  of  human  habitations;  the  Anopheles  also  travels  farther. 
"  Compared  to  yellow  fever,  the  control  of  the  malarial  human  host 
presents  special  difficulties.  In  yellow  fever  man  is  infective  to  the 
Stegomyia  only  a  few  days;  in  malaria  the  parasites  continue  in  the 
circulating  blood  a  very  long  time.  In  the  case  of  malaria,  then,  we 
have  to  deal  with  chronic  carriers,  which,  fortunately  for  us,  does  not 
occur  in  yellow  fever.  For  malaria  we  have  quinine  as  a  prophylactic, 
whereas  no  known  drug  will  prevent  yellow  fever."  ("  Preventive 
Medicine  and  Hygiene,"  1913,  p.  220.) 


2IO  A  MANUAL   FOR   HEALTH   OFFICERS 

OTHER   INSECT-BORNE   DISEASES 

PLAGUE 

In  the  dissemination  of  plague,  rats  and  rat-fleas  play 
the  most  important  part.  Tliis  disease,  caused  by  the 
Bacillus  pestis,  is  "  primarily  a  disease  of  the  rat  and  sec- 
ondarily of  man  "  (Rosenau).  It  is  transmitted  to  man 
by  the  bite  of  the  rat-flea.  (Suspicion  has  also  been 
thrown  on  other  insects.)  In  man  it  occurs  in  the  bubonic, 
the  pneumonic,  and  the  septicemic  types.  In  the  second 
type,  plague  pneumonia,  the  sputum  is  highly  infectious 
and  the  disease  may  be  transmitted  by  contact.  In  the 
other  types  the  bacilli  are  contained  within  the  body.  Mild, 
ambulant  cases  occur  ("pestis  minor"). 

Control.  —  Cases  of  the  disease  should  be  diagnosed  as 
early  as  possible,  for  which  purpose  bacteriological  facilities 
are  indispensable.  In  emergency,  traveling  laboratories 
may  be  furnished  by  state  or  federal  authorities  in  order 
that  the  service  may  be  available  promptly  on  the  spot. 
Cases  should  be  isolated  and  disinfection  of  all  discharges 
practised.  Persons  subject  to  exposure  may  be  immunized 
with  Yersin's  antiplague  serum,  or,  better,  by  inoculation 
W'ith  Haffkinc's  prophylactic. 

The  radical  public  health  measure  is,  however,  destruc- 
tion of  rats  and  of  other  rodents  (e.g.,  as  in  California, 
ground  squirrels)  which  may  become  infected  and  transmit 
tlie  disease  through  their  fleas.  The  numbers  of  rats  in  all 
populated  districts  are  enormous  and  much  economic 
benefit  as  well  as  sanitary  protection  results  from  their 
suppression.  Rats  also  play  a  part  in  the  propagation  of 
trichinosis  and  other  diseases  of  man.  An  extended  dis- 
cussion of  the  methods  of  plague  prevention  through  rodent 
extermination  cannot  be  given  here.^ 

1  See  Rosenau:  "  Preventive  Medicine  and  Hygiene,"  1913,  p. 
240  ff.;  also  "  The  Rat  and  Its  Relation  to  the  Public  Health,"  Bull., 
U.  S.  Public  Health  and  Marine-Hospital  Service,  1910  (obtainable 
from  the  Surgeon-General,  U.  S.  P.  H.  S.,  or  the  Supt.  of  Documents, 
Washington,  D.  C). 


COMMUNfCABr.K   DISKASE  211 

Other  insects  and  vermin  —  e.g.,  varimis  fleas,  ticks,  lice, 
bed-bugs,  etc.  —  have  been  incriminatecl  or  are  suspected 
of  transmitting  various  communicable  diseases. 

Typhus  fever  ("ship  fever,"  "jail  fever,"  "camp  fever," 
etc.),  for  example, — ^  which  was  once  widely  prevalent, 
though  now  rare,  in  civilized  communities,  —  is  transmitted 
solely  through  the  bite  of  the  louse.  Typhus  fever  was 
once  confused  with  (though  now  recognized  as  quite  dis- 
tinct from)  typhoid  fever;  it  has  in  recent  years  been 
rediscovered  under  the  name  of  "  Brill's  Disease."  It  is 
prevented  through  the  elimination  of  the  louse.  Its  oc- 
currence has  naturally  a  close  connection  with  filthy,  over- 
crowded, unhygienic  living  conditions.  Other  diseases  of 
this  class,  such  as,  e.g.,  relapsing  fever  (spread  by  ticks 
and  other  biting  insects),  are  also  rare  under  civilized 
conditions,  being  eliminated  by  cleanliness  and  freedom 
from  vermin. 

The  other  diseases  of  this  class  are  chiefly  of  interest  to 
students  of  tropical  sanitation  and  parasitology  and  to 
quarantine  officials,  and  need  not  be  mentioned  here. 

IV.  DISEASES    HAVING    SPECIFIC    OR    SPECIAL 
PREVENTIVE    MEASURES 

SMALLPOX 

Smallpox  (variola)  is  the  most  highly  communicable  of 
all  the  major  diseases  with  which  health  authorities  have 
to  deal.  But  it  is  also,  fortunately,  the  most  surel}'  pre- 
ventable, for  vaccination  furnishes  the  means  of  making 
whole  communities  practically  immune. 

Transmission.  —  The  smallpox  virus,  the  exact  nature 
of  which  is  unknown,  is  present  in  the  skin  lesions.  It  is 
so  "volatile"  that  contact  infection  very  readily  occurs. 
Smallpox  and  measles  are  alike  in  their  extreme  contagious- 
ness. Smallpox  has  long  been  considered  an  air-borne 
infection.     While  there  is  evidence  that  this  is  to  a  certain 


212  A  MANUAL   FOR  HEALTH   OFFICERS 

extent  true,  the  tendency  of  modern  authorities  is  to  re- 
gard the  radius  of  air  infection  as  much  smaller  than  form- 
erly supposed.  Certainly  air  infection  out  of  doors  is  prac- 
tically nil.  Chapin,  concluding  a  careful  study  of  the 
evidence,  asserts  that  "the  evidence  in  favor  of  the  aerial 
transmission  of  smallpox  from  hospitals  is  so  slight  that  it 
should  never  influence  a  municipality  in  its  selection  of  a 
hospital  site."  ^ 

Not  only  the  skin  but  also  all  discharges  of  any  kind  from 
the  patient  should  be  regarded  as  possibly  infectious. 
Direct  and  indirect  contact,  fly  infection,  and  even  fomites, 
should  be  guarded  against.  The  patient  is  infectious  before 
the  eruption  occurs  and  possibly  during  the  period  of  in- 
cubation. 

Incidence.  —  Smallpox  may  thrive  anywhere  at  any 
time  among  susceptible  persons  of  all  ages  and  conditions. 
It  shows  no  regularities  of  distribution,  although  it  has  a 
tendency  to  recur  in  waves  separated  by  several  years ;  this 
may  be  due  to  the  growth  of  fresh  material  in  the  popula- 
tion. Its  virulence  varies  from  time  to  time.  Although 
smallpox  is  not  endemic  in  communities  in  this  country, 
it  is  constantly  present  in  small  foci  here  and  there  in  various 
States,  and  no  community  is  immune  from  the  possibility 
of  an  epidemic.  A  warning  of  this  fact  is  to  be  seen  in 
the  1913  Niagara  Falls  epidemic,  in  which  196  cases 
occurred  in  that  town  of  30,000  population.  Disastrous 
epidemics  have  in  several  instances  in  recent  years  been 
started  by  the  introduction  of  a  single  case.  The  disease 
is  so  contagious  that  improvements  in  general  sanitation 
practically  do  not  affect  it. 

Control  depends  upon  vaccination,  for  isolation  alone 
cannot  practically  be  relied  upon.  Not  only  is  smallpox 
extremely  contagious,  but  "unrecognized  cases  .  .  .  are 
so  numerous  that  the  isolation  of  the  recognized  cases 
often  seems  to  be  a  complete  failure"  (Chapin).  Such 
'  "  Sources  and  Modes  of  Infection,"  1910,  p.  224. 


COMMUNICABLE  DISEASE  213 

mild  or  atypical  cases  may  readily  f^ive  rise  to  severe  cases; 
hence  their  detection  —  so  far  as  possible  —  is  of  great 
importance.  Vaccination  before  exposure  is  a  nearly  pc^r- 
fect  protection.  This  holds  good  also  of  vaccination  up  to 
the  sixth  or  eighth  day  of  incubation;  and  even  at  this 
time  it  may  modify  the  course  of  the  disease.  Persons  in 
any  stage  of  the  incubation  period  should  be  vaccinated,  f(jr 
the  exact  date  of  exposure  may  not  be  known,  the  incuba- 
tion may  be  a  prolonged  one,  and  there  is  at  any  rate  a 
chance  of  modifying  if  not  of  preventing  entirely  the  devel- 
opment of  the  disease.  Even  when,  as  exceptionally 
occurs,  the  protection  is  not  perfect  and  the  disease  is  con- 
tracted, it  is  in  the  modified  and  milder  form  of  varioloid. 
We  re/er,  whenever  vaccination  is  mentioned,  to  successful 
vaccination;  a  satisfactory  "take"  must  be  obtained, 
though  two  or  more  inoculations  are  required  in  some 
cases. 

Objections  to  vaccination  are  based  upon  the  arguments 
that  it  does  not  invariably  protect  and  that  blood  infections 
have  resulted  from  vaccinations  with  poor  vaccine  or  im- 
properly performed.  While  there  is  a  small  basis  of  fact 
in  both  the  assertions,  a  glance  at  the  benefits  of  vaccina- 
tion is  sufficient  to  show  that  these  vastly  outweigh  the 
incidental  drawbacks.  Anti-vaccination  argument  may 
therefore  stimulate  care  in  the  application  of  the  process  and 
accuracy  in  the  statements  of  health  officers,  but  is  no 
valid  objection,  as  world-wide  experience  proves.  "In  the 
Philippine  Islands  in  the  past  few  years  the  United  States 
authorities  vaccinated  3,515,000  persons  without  a  single 
death  or  any  serious  post-vaccinal  complications."  ^ 
The  indicated  administrative  measures  are  as  follows: 
I.  Registration  of  Cases.  —  This  includes  suspicious 
cases,  and  the  health  authorities  should  be  prepared  to 
furnish  medical  assistance  in  making  diagnosis.     Chicken- 

^  For  a  complete  discussion  of  vaccination  see  Rosenau,  "  Preven- 
tive Medicine  and  Hygiene,"  1913,  p.  i  ff. 


214  A  MANUAL  FOR  HEALTH  OFFICERS 

pox,  on  account  of  its  resemblance  to  smallpox,  should  be  a 
reportable  disease,  and  in  the  presence  of  smallpox  in  the 
community  physicians  should  be  warned  and  suspicious 
cases  of  chickenpox  should  be  medically  inspected.^ 

Not  infrequently  cases  of  smallpox  having  no  medical 
attendance  come  to  light  in  public  conveyances,  lodging 
houses,  and  other  places.  Credible  rumors  of  cases  should 
be  investigated. 

2.  Isolation,  with  disinfection  of  mouth  and  nose  dis- 
charges, feces,  and  urine  (do  not,  however,  use  carbolic 
acid  or  cresols),  should  be  practised.  Although  isolation 
in  smallpox  is  only  of  secondary  value,  it  is  of  use  in  less- 
ening the  possibilities  of  infection,  particularly  when  the 
cases  are  few.  If  a  case  of  smallpox  is  introduced  iuto  a 
previously  smallpox-free  community,  it  is  the  duty  of  the 
health  authorities  to  take  prompt  and  stringent  precautions 
in  isolation  and  disinfection,  as  well  as  in  vaccination  of 
contacts  as  explained  below. 

'  The  differential  diagnosis  between  smallpox  on  the  one  hand  and 
chickenpox  and  other  diseases  on  the  other  is  important.  Clinically, 
distinction  is  made  primarily  by  the  character  of  the  eruption,  and  not 
by  the  constitutional  symptoms,  which  may  be  absent  or  atypical. 
The  smallpox  eruption  in  the  first  stages  is  hard  and  "  shotty  "  and 
extends  into  the  true  skin,  while  the  chickenpox  vesicles  are  superficial 
and  easily  broken.  The  eruption  in  chickenpox  comes  out  in  successive 
distinct  crops  (while  that  of  smallpox  never  does),  and  there  is  compar- 
atively little  eruption  of  chickenpox  on  hands  and  feet.  (See  Doty, 
"  Prevention  of  Infectious  Diseases,"  1911,  p.  58  fT.)  DifTerentiation 
may  also  be  effected  by  inoculation  of  some  of  the  virus  (heated  to  60°  C. 
for  30  minutes)  into  the  skin  of  a  well-vaccinated  person:  if  smallpox, 
a  typical  "  immediate  "  reaction  occurs,  i.e.,  in  less  than  24  hours 
(see  Rosenau,  "  Preventive  Medicine  and  Hygiene,"  1913,  p.  17). 
Histological  examination  of  the  pock  and  inoculation  upon  the  cornea 
of  rabbits,  are  additional  differential  methods  (see  Rosenau,  ibid., 
pp.  280-281).  When  there  is  any  doubt  in  the  mind  of  the  practitioner 
or  health  department  physician,  the  case  should  be  treated  as  if  small- 
pox and  expert  diagnostic  aid  should  be  at  once  secured.  In  places 
where  smallpox  occurs  infrecjuently  the  state  health  authorities  should 
be  notified  by  telegraph  or  telephone  and  their  assistance  requested. 


coMMUNicAfUj';  DisroASi-:  215 

Isolation  should  he  of  ihc  strictest  character.  Unless 
home  conditions  are  exceptional,  the  [)atient  should  he 
removed  to  a  special  hospital,  which  it  may  be  necessary 
to  establish  in  a  vacant  house  or  even  in  tents.  Such  a 
hospital  need  not,  liowever,  be  the  desolate  "pest-house" 
of  former  days,  but  may  be  a  special  department  of  a  regular 
contagious  disease  hospital.  As  already  remarked,  a  small- 
pox hospital,  if  properly  conducted,  need  not  be  located  at 
a  distance  from  other  habitations.  Fly  transmission  should 
be  guarded  against  by  proper  screening.  On  account  of 
the  dillficulties  and  expense  of  establishing  proper  emer- 
gency hospitals  for  smallpox,  every  community  sliould 
have  access  to  a  ward  or  hospital  always  prepared,  in  con- 
nection with  a  municipal  or  county  isolation  hospital.  Iso- 
lation should  be  permitted  in  a  private  house  only  if  it 
can  be  perfectly  maintained  and  a  trained  nurse  is  in  at- 
tendance. Articles  which  may  have  been  infected  by  the 
patient  before  or  after  isolation  should  be  destroyed  or 
thoroughly  disinfected,  and  if  he  is  removed  to  the  hospital 
the  apartment  occupied  by  him  should  be  disinfected. 
The  precaution  of  terminal  room  disinfection  after  recovery 
should  also  be  practised. 

3.  Vaccination,  as  already  remarked,  is  the  measure 
upon  which  chief  reliance  is  to  be  placed.  Even  the  best 
isolation  of  cases  cannot  take  its  place.  All  persons  who 
have  possibly  been  exposed  to  a  case  of  smallpox  should 
promptly  be  vaccinated.  Exception  can  only  be  made  of 
persons  who  have  had  a  positively  successful  vaccination 
but  a  short  time  previous.  In  nearly  all  cases  vaccination 
will  prevent  the  development  of  smallpox  if  taken  promptly 
after  exposure.  Persons  of  intelligence  may  then  be  per- 
mitted to  go  without  further  olificial  surv^eillance,  though 
they  should  be  advised  to  consult  a  physician  if  any  symp- 
toms appear  within  two  weeks  from  last  possible  exposure 
(accepted  for  practical  purposes  as  the  maximum  incuba- 
tion period) .     Such  persons  will  probably  do  so,  being  appre- 


2l6  A  MANUAL   TOR   HEALTH   OFFICERS 

hensive;  but  if  there  is  any  question  they  should  be  kept 
under  sur\'eillancc,  being  required  to  report  to  their  own 
or  the  health  department  physician  for  medical  examination 
each  day  for  the  period  mentioned.  Ignorant  and  careless 
persons  should  always  be  strictly  required  to  submit  to 
such  surveillance.  When  a  case  of  smallpox  occurs  in  a 
crowded  tenement,  public  building,  or  other  place  where 
there  are  many  persons,  every  person  who  is  suspected  of 
ha\ing  been  at  all  exposed  should  be  vaccinated,  which 
may  mean  a  very  considerable  number  of  persons. 

The  health  authorities  should  constantly  keep  on  hand 
fresh  vaccine  virus  from  a  reliable  source,  and  should  be 
prepared  to  obtain  larger  quantities  at  short  notice.  Virus 
may  now  be  obtained  which  produces  a  successful  vacci- 
nation in  nearly  loo  per  cent  of  previously  unvaccinated 
persons,  but  it  must  be  exchanged  for  fresh  virus  at  cer- 
tain intervals  recommended  by  the  manufacturer.  Vac- 
cine virus  which  enters  into  interstate  commerce  must  come 
from  a  manufacturer  licensed  by  the  Federal  authorities. 
Provision  should  be  made  for  free  vaccination  of  indigent 
persons. 

The  state  authorities  should  be  notified  by  telegraph  of 
any  case  of  smallpox  appearing  in  a  community,  so  that 
any  needed  cooperation  may  be  obtained  without  delay. 
No  pains  or  expense  should  be  spared  to  stamp  out  the 
disease  at  the  onset  of  the  first  case,  a  principle  which  also 
applies  to  other  severe  infections.  If  an  epidemic  threatens, 
a  strong  authority,  centered  in  one  person,  should  be  es- 
tablished, and  adequate  emergency  funds  should  at  once 
be  voted  by  the  local  government.  It  may  be  necessary 
to  undertake  a  campaign  for  more  or  less  general  vaccina- 
tion. An  ample  supply  of  vaccine  should  be  promptly 
secured,  and  free  vaccination  oflfered  and  performed  for 
persons  unable  to  pay,  and  vaccinating  physicians  (espe- 
cially engaged  if  necessary)  should  make  a  canvass  in  the 
infected  neighborhood.     In  a  serious  epidemic  school  chil- 


COMMUNICABLE  DTSEASI-;  217 

dren  should  certainly  he  vaccinated.  Employees  of  hos- 
pitals, factories,  wc^rkshops,  hotels,  etc.,  may  recjuirc  j^cn- 
eral  vaccination.  Cases  should  he  removed  to  the  isolation 
hospital,  as  has  already  heen  mentioned,  so  far  as  ac- 
commodations permit,  hut  s[)ecial  emergency  hospitals 
may  be  required.  A  diligent  search  should  he  made  for 
concealed  cases  and  for  unrecognized  cases;  persons  re- 
ported as  having  suspicious  chickenpox  should  he  medi- 
cally examined. 

What  measures  should  the  health  authorities  take  at 
times  when  smallpox  is  not  present?  Since  two  successful 
vaccinations  usually  protect  against  smallpox  for  life,^  the 
question  is  largely  one  of  securing  the  vaccination  of  in- 
fants and  school  children.  This  is  the  vexed  question  of 
compulsory  vaccination.  The  results  of  compulsory  vac- 
cination as  practised  in  foreign  countries  (particularly  in 
Germany,  where  it  is  compulsory  for  infants  before  the 
end  of  the  first  year  of  life  and  again  at  the  twelfth  year) 
indicate  clearly  the  great  benefits  of  the  measure  (Rose- 
nau).  In  countries  where  it  has  been  left  merely  optional, 
other  conditions  being  comparable,  the  incidence  of  small- 
pox has  been  many  times  greater.  If  vaccination  of  the 
growing  generation  is  neglected,  there  develops  a  large  un- 
vaccinated  and  non-immune  population  the  numbers  of 
which  run  a  certain  risk  of  coming  in  contact  with  unrecog- 
nized cases  of  the  disease.  The  importation  of  such  a  case 
into  such  a  community  may  readily  start  an  epidemic  more 
difificult  to  control  than  it  would  be  if  the  whole  population 
had  at  least  a  moderately  good  vaccinal  status.  While 
such  facts  indicate  the  desirability  of  vaccination  of  in- 
fants and  children,  and  the  Supreme  Court  of  the  United 
States  and  other  courts  have  held  such  a  requirement  to 
that  effect  to  be  constitutionally  valid,  nevertheless  there 

^  To  secure  complete  immunity  persons  should  be  revaccinated  on 
an  average  of  every  seven  years.  (Rosenau,  "  Preventive  Medicine 
and  Hygiene,"  1913,  pp.  15,  17.) 


2lS  A  MANUAL   FOR  HEALTH  OFFICERS 

is  considerable  public  sentiment,  growing  in  intervals  of 
absence  of  the  disease,  to  the  contrary.^ 

In  some  states  the  power  to  require  vaccination  of  school 
children  rests  with  the  school  authorities.  The  health 
authorities  should  favor  such  a  measure.  Some  publicity 
may  be  desirable.  In  places  where  vaccination  of  children 
before  admittance  to  school  is  required,  there  is  likely  to 
be  considerable  friction  in  enforcement  unless  a  "conscience 
clause"  in  the  law  permits  parents  to  exempt  their  children 
on  the  ground  of  personal  objections.  The  least  that  can 
be  done  by  health  authorities  is  to  inform  the  public  as  to 
the  value  of  vaccination,  supply  reliable  vaccine  at  cost 
(free  to  persons  unable  to  pay),  recommend  the  vaccination 
and  revaccination  of  infants  and  children,  and  reserve  the 
power  to  enforce  vaccination  so  far  as  deemed  necessary 
in  the  immediate  infection  area  of  each  case  that  may 
appear.2 

RABIES 

"Rabies  [hydrophobia]  is  an  acute,  specific,  rapidly  fatal 
infection  communicated  from  a  rabid  animal  to  a  suscep- 
tible animal,  usually  through  a  wound  produced  by  biting, 
Man  always  contracts  the  disease  from  some  lower  animal, 
usually  the  dog. "     (Rosenau.) 

Notwithstanding  the  fact  that  this  dread  but  wholly  pre- 
ventable disease  occurs  in  the  United  States,  both  in 
animals  and   in  man,   to  an  alarming  extent,  very  little 

^  In  Minnesota  the  state  health  authorities  have  acceded  to  popular 
clamor  against  vaccination  laws  and  have  even  given  up  isolation  in 
smallpox,  maintaining  that  protection  is  purely  an  individual  matter, 
the  option  lying  with  the  person  as  to  whether  he  does  or  does  not  care 
to  protect  himself  by  means  of  vaccination. 

2  The  laws  relative  to  vaccination  in  the  United  States  are  many  and 
varied.  In  the  majority  of  states  its  adoption  is  optional  with  the 
local  health  authorities.  See  "  Vaccination:  an  AnaKsis  of  the  Laws 
and  Regulations  Relating  Thereto  in  Force  in  the  United  States," 
Public  Health  Bull.  No.  52,  U.  S.  Public  Health  Service,  Washington, 
D.  C,  1912. 


COMMUNICABI.K    DISKASIC  219 

control  is  exerted  over  it.  This  state  of  affairs  is  due  to 
failure  of  health  officials  and  public  to  realize  the  impor- 
tance of  the  disease  and  to  recognize  it  when  it  appears. 

Transmission.  —  The  virus  exists  in  the  saliva  of  infected 
animals  (possibly  8  days  before  symptoms)  and  is  usually 
transmitted  to  man  through  bites.  The  usual  source  is 
the  dog,  though  other  mammalian  animals  are  suspectible 
to  it  and  may  both  contract  and  transmit  the  infection. 
Among  these  are  mentioned  cats,  wolves,  foxes,  skunks, 
cattle,  sheep,  goats,  horses,  and  swine.  But  inasmuch  as 
infection  under  ordinary  circumstances  is  from  the  dog  we 
shall  confine  our  discussion  largely  to  that  source.^ 

Infection  is  not  necessarily  by  biting,  —  the  mere  lick- 
ing of  the  bare  hand  or  face  by  a  rabid  animal  may  result 
in  infection  if  cuts  or  abrasions  exist.  Even  where  such 
breaks  in  the  skin  are  not  visible  to  the  eye,  infection  is 
possible.  Hence  the  rule  is  to  handle  any  sick  dog  with 
thick  gloves  and  to  protect  one's  face,  until  positive  that 
the  sickness  is  not  rabies.  Bites  through  the  clothing  may 
result  in  infection,  though  not  so  readily  as  those  on  the 
unprotected  parts  of  the  body.  Bites  upon  the  face  are 
particularly  dangerous,  for  the  virus  has  there  quicker 
access  to  the  nervous  system,  which  is  its  object  of  attack. 
Infection  may  take  place  in  dissections  of  the  bodies  of 
animals  which  have  died  of  the  disease,  the  virus  existing 
in  the  nervous  system. 

The  incubation  period  of  rabies  in  man  is  40  daj's  on  the 
average,  but  varies  from  14  days  to  a  year  or  more  (Rose- 
nau).  In  dogs  the  average  is  21  to  40  days.  This  long 
period  is  fortunate  for  preventive  treatment,  but  unfor- 
tunate in  that  it  diverts  popular  attention  from  the  disease 
between  occurrences  and  makes  general  measures  of  pre- 

^  Wherever  in  this  section  the  word  "  animal  "  is  used  it  is  meant 
to  apply  chiefly  to  dogs.  The  measures  recommended  for  control  of 
rabies  in  dogs  may  be  adapted  to  apply  when  necessary  to  rabies  in 
other  animals. 


2  20  A  MANUAL   FOR  HEALTH  OFFICERS 

vention  more  difficult  to  enforce.  A  dog  runs  through  a 
town  and  bites  a  number  of  persons  and  dogs;  there  is  an 
excitement  which  soon  dies  out.  In  the  course  of  several 
months  some  more  dogs  develop  rabies,  —  again  some 
excitement,  several  dogs  are  killed,  and  then  again  the 
matter  is  forgotten.  In  the  long  run  a  grave  problem  is 
much  under-rated  simply  because  the  cases  are  so  dis- 
tributed. 

Incidence.  —  Rabies  may  develop  in  any  person  bitten 
by  a  rabid  animal  (unless  the  Pasteur  treatment  is  given  — 
see  below),  and  if  it  does  develop  is  invariably  fatal.  It 
occurs  to  an  absolutely  unwarranted  extent  in  the  United 
States:  in  191 1  there  were  1381  localities  in  which  rabid 
animals  were  reported  and  98  deaths  in  man  (Rosenau), 
and  it  is  apparently  on  the  increase  in  many  regions. 
Rabies  undoubtedly  occurs  to  a  greater  extent  than  is 
shown  by  the  figures,  for  there  may  be  failure  to  rightly 
diagnose  sporadic  cases.  Some  deaths  from  rabies  have 
probably  been  ascribed  to  cerebrospinal  fever  and  other 
diseases.  For  example,  a  patient  taken  to  a  hospital  with 
slight  temperature  and  pain  becomes  violent  and  dies  in  a 
few  hours.  No  diagnosis,  and  on  autopsy  nothing  found 
except  congestion  of  the  brain.  The  suggestion  of  rabies 
is  made.  Animal  inoculations  are  made  and  prove  the 
case  one  of  rabies.  It  is  a  great  chance  in  such  cases  that 
the  disease  goes  unrecognized.  With  children  symptoms 
may  be  even  more  puzzling.  Young  children  may  be 
slightly  bitten  by  rabid  dogs  without  the  knowledge  of  the 
parents.  And  frequently  the  dog-bite  which  caused  the 
infection  happened  so  many  weeks  before  that  it  has  been 
entirely  forgotten. 

Moreover,  to  the  actual  mortality  from  an  agonizing 
and  unnecessary  form  of  death  must  be  added  the  time  and 
money  incident  to  taking  the  Pasteur  treatment  in  hundreds 
of  cases,  and  the  grave  anxiety  involved. 

Such  facts  indicate  the  gravity  of  the  rabies  problem. 


COMMUNICAIUJO    IHSKASK  221 

Rabies  occurs  at  all  seasons,  though  the  popular  idea  that 
rabies  is  a  hot-wcathcr  disease  is  true  in  (hal  dogs  run  more 
freely  at  large  in  the  summer  season  and  thus  incur  and 
transmit  infection  more  readily.  I)istemf)er,  which  is 
sometimes  popularly  confused  with  rabies,  is  also  perhaps 
more  prevalent  in  hot  weather. 

Recognition  of  Canine  Rabies.  —  The  symptoms  of  the 
disease  in  dogs  are  sketched  in  the  information  given  on 
page  224  (footnote),  and  should  be  recognized  by  all  per- 
sons having  charge  of  dogs,  as  well  as  by  health  officers  and 
inspectors. 

Dogs  suffering  with  rabies  may  not  by  any  means  show 
all  the  text-book  symptoms,  nor  do  they  always  behave 
as  the  popular  idea  of  a  mad  dog  would  lead  one  to  expect. 
They  do  not  fear  water  (though  paralysis  of  the  throat 
muscles  in  the  late  stages  of  the  disease  may  hinder  them 
from  drinking  it) ;  hence  the  term  hydrophobia,  signifying 
"fear  of  water,"  is  incorrect.  The  one  unfailing  symptom 
is  the  paralysis  which,  beginning  with  the  hind-legs,  in- 
variably develops  before  death. 

In  the  furious  type  of  rabies  the  animal  is  highly  restless 
and  has  a  tendency  to  run  long  distances  biting  any  per- 
sons and  other  animals  in  his  way.  This  is  the  popularly 
recognized  mad  dog.  But  in  the  dumh  type  of  the  disease 
the  animal  is  quiet  and  depressed  and  does  not  show  the 
same  tendency  to  wander  and  bite,  though  if  a  wound  is 
received  from  this  type  it  is  as  dangerous  as  from  the  other. 
The  following  account,  by  a  physician,  is  illustrative: 

A  man  came  to  my  office  some  years  ago  with  a  small  punctate  wound 
of  the  face.  He  stated  that  he  had  been  called  by  one  of  his  neighbors 
to  shoot  a  sick  dog.  In  pulling  the  dog  out  of  the  kennel  he  received  a 
wound,  he  did  not  know  whether  from  a  tooth  or  from  the  dog's 
paw.  I  asked  him  to  describe  the  dog's  condition,  and  he  made  the 
following  statement.  The  dog  had  been  sick  for  several  days,  refusing 
to  eat,  and  remaining  in  his  kennel.  He  also  stated  that  the  dog  had 
a  broken  jaw  and  could  not  close  his  mouth;  the  tongue  was  quite 
black. 


222  A   MANUAL   FOR   liEALlII   ()!■  !■  ICIIRS 

.  This  man  died  fi\c  weeks  later  a  horrible  death  from  hydrophobia. 
Had  I  then  known  that  the  supposed  broken  jaw  was  the  paral>sis  of 
this  [dumb]  form  of  rabies  my  patient  might  have  received  the  Pasteur 
treatment,  and  not  have  been  a  victim  of  this  disease. 

And,  it  might  have  been  added,  if  the  owner  of  the  dog 
had  had  some  conception  of  the  symptoms  of  rabies  the 
proper  care  might  have  been  taken  and  the  infection  might 
thus  have  been  entirely  avoided. 

Diagnosis.  —  Diagnosis  on  the  symptoms  is  uncertain 
and  should  be  confirmed  by  laboratory  methods.  The 
first  of  these  is  the  microscopic  examination  of  the  brain 
substance  for  the  presence  of  the  "Negri  bodies."  The 
finding  of  these  bodies  shows  at  once  the  existence  of  rabies. 
Failure  to  find  them  does  not,  however,  necessarily  signify 
that  the  animal  did  not  have  rabies,  for  they  may  miss 
detection.  If  the  Negri  bodies  are  not  found  it  is  necessary 
to  make  animal  inoculations,  Avhich  are  the  most  reliable 
test,  but  generally  several  weeks  will  be  required  for  the 
disease,  if  present,  to  develop  in  the  test  animals. 

//  a  dog  is  suspected  of  rabies  it  should  not  be  killed  (un- 
less safety  requires)  but  should  be  securely  chained  (a 
rope  may  be  chewed  through)  within  an  enclosure  which 
will  exclude  all  persons  and  other  animals.  If  sufi^ering 
from  rabies,  the  dog  will  develop  paralysis  and  die,  usually 
in  four  or  five  days.  If,  on  the  contrary,  the  dog  is  alive 
and  sound  at  the  end  of  ten  days,  it  may  then  be  released 
without  danger. 

If  necessary  to  kill  the  animal,  the  brains  should  not  be 
blown  out,  but  the  head  should  be  kept  as  nearly  intact  as 
possible.  The  carcass  (if  the  dog  is  large,  the  head  only) 
is  then  packed  in  ice  in  a  watertight  container  and  for- 
warded by  rush  service  to  a  laboratory  for  the  examina- 
tions which  have  already  been  described.  The  head  should 
be  severed  as  close  to  the  thorax  as  possible,  with  sharp 
instruments  (knife  and  saw).  In  order  to  avoid  infection 
the  operator  should  protect  the  skin  of  the  hands  with  thick 


COMMUNTCAIM.K    I)IS[':ASE  223 

gloves  and  exercise  cleanliness  f(;li(>wecl  hy  disinfeclion  of 
gloves,  implements,  and  hands.  The  carcass  after  sever- 
ance of  head  should  be  burned  or  deeply  buried. 

Prevention.  —  Eradication,  prompt  and  practically  abso- 
lute, will  result  from  drastic  measures  relating  to  the  con- 
trol of  dogs.  In  England  and  Australia,  owing  to  such 
measures,  rabies  is  now  non-existent.  The  use  of  I-*asteur 
preventive  treatment  is  of  the  greatest  importance  in  per- 
sonal prophylaxis,  but  has  nothing  to  do  with  the  proper 
eradication  of  the  disease. 

We  shall  speak  first  of  the  general  measures  which  should 
be  taken  by  health  authorities. 

I.  Muzzling  and  Quarantine.  —  The  most  immedi- 
ately effectual  measure  is  to  require  the  muzzling  of  all 
dogs  at  large  and  the  killing  of  all  ownerless  dogs.  Such 
measures  must  be  strictly  and  universally  enforced  over  a 
wide  area,  such  as  the  state,  and  there  must  be  active  dog- 
wardens  to  capture  the  stray  and  ownerless  dogs  and  dogs 
whose  owners  allow  them  out  without  a  muzzle.  Such 
measures,  in  conjunction  with  a  national  quarantine  of  six 
months  against  dogs  entering  the  country,  has  freed  Eng- 
land entirely  from  rabies  in  dog  or  man.  Two  years  of 
such  a  regime  will  practically  exterminate  the  disease,  and 
then,  unless  it  reappears,  the  muzzling  (but  not  the  quar- 
antine) may  be  discontinued.^ 

Leashing  as  a  requirement  has  been  sometimes  tried,  but 
appears  not  to  be  entirely  effective. 

The  above  measures  of  general  muzzling  for  a  certain 
period  and  a  national  quarantine  are  undoubtedly  the  most 
radical  and  effective.  They  require,  however,  a  general 
law  generally  enforced.  Strong  state  laws  (cf.  page  231) 
should  be  adopted  and  should  ultimately  lead  to  such  com- 
plete control.  Meanwhile  measures  of  the  following  classes 
will  afford  a  certain  degree  of  local  protection. 

^  For  further  information  see  Rosenau,  "  Preventive  Medicine  and 
Hygiene,"  1913,  p.  36  flf. 


224  A  MANUAL  FOR  HEALTH  OFFICERS 

2.  Registration  of  Dogs.  —  It  is  essential  that  all 
dogs  be  registered  (licensed).  The  registration  should  be 
controlled  by  the  health  authorities  as  a  fundamental  step 
in  the  prevention  of  rabies.  Inasmuch  as  dogs  constitute 
the  principal  reservoir  of  rabies  infection,  this  consider- 
ation should  outweigh  all  others,  and  the  health  authorities 
should  be  vested  with  this  means  toward  the  suppression 
of  a  disease  which  falls  in  the  regular  category  of  commu- 
nicable diseases.  Registration  should  not  be  entrusted  to 
humane  societies  or  other  unofficial  bodies. 

Registration  is  not  merely  an  indexing  of  the  canine 
population,  it  is  more  especially  for  the  purpose  of  fixing 
a  certain  responsibility  upon  the  owners  of  dogs.  The  fee 
charged  should  not  be  so  high  as  to  make  the  keeping  of  a 
dog  a  luxury,  but  should  be  high  enough  to  ensure  a  distinct 
interest  on  the  part  of  the  owner  and  to  discourage  the 
keeping  of  dogs  by  irresponsible  persons.  Registration  has 
a  special  value  in  that  it  enables  the  health  authorities  to 
reach  the  owners  with  educational  measures  (see  below). 

Registered  dogs  should  be  tagged  with  a  tag  distinctive 
for  each  year,  and  all  untagged  dogs  on  the  streets  should  be 
taken  up  by  a  vigilant  dog  warden,  to  be  destroyed  if  not 
claimed  and  registered.  Upon  this  depends  the  whole 
operation  of  the  law,  the  greatest  value  of  which  lies  in  doing 
away  with  stray  and  ownerless  dogs.  It  is  just  this  last 
class  of  animals  which,  wandering  about  and  picking  up 
and  distributing  any  rabies  infection  which  may  exist,  is 
most  dangerous. 

3.  Instruction  of  Dog-Owners.  —  Every  person  regis- 
tering a  dog  should  receive  printed  information  (preferably 
printed  on  the  license  receipt  so  as  to  be  kept  for  reference), 
to  be  explained  orally  if  necessary,  giving  (i)  the  ordinances 
relative  to  the  keeping  of  dogs  (see  page  229),  and  (2)  the 
symptoms  of  rabies.^     It  is  a  fact  that  scarcely  any  of  the 

1  The  following  form,  headed  "  RABIES,"  may  be  used: 
"  Rabies  is  an  infectious  disease  which  may  attack  dogs,  cats,  and 
other  warm-blooded   animals  and   which   may   be  communicated   to 


COMMUNICABLE   DISEASE  225 

persons  responsible  for  the  care  of  dogs  arc  acquainted  with 
the  symptoms  —  especially  the  early  symptoms  —  of  the 

human  beings,  in  whom  it  is  usually  called  hydrophobia.  It  may  occur 
at  any  season,  winter  as  well  as  summer. 

"  The  onset  of  rabies  in  the  dog  is  sometimes  unrecognized  by  it3 
owner  as  there  are  considerable  variations  in  the  symptoms,  and  many 
of  the  cases  do  not  show  the  violent  symptoms  popularly  associated 
with  the  '  mad  dog.'  It  .should  be  remembered  that  rabies  makes  the 
dog  sick  and  causes  him  to  act  strangely,  dying  within  a  few  days  — 
usually  four  or  five. 

"  Two  forms  of  the  disease  commonly  occur:  the  quiet  or  dumb  form, 
and  the  active  or  violent  form.  In  the  first  the  dog  is  depressed  and  drowsy 
and  shows  little  or  no  tendency  to  bite  or  run  away.  The  lower  jaw  is 
slightly  dropped,  and  although  the  animal  laps  liquids  freely  he  is 
unable  to  swallow  them.  He  may  be  thought  to  have  '  a  bone  in  his 
throat '  because  he  does  not  care  to  eat.  Weakness  of  the  hind  legs 
sets  in,  and  the  animal  dies  within  a  few  days. 

"  In  the  second  form  the  animal  is  restless,  sometimes  irritable,  and 
sometimes  unusually  affectionate  (in  the  onset).  The  voice  is  changed 
to  a  peculiar  howl.  Frequently  the  dog  runs  away  from  home.  Later, 
weakness  of  the  legs  sets  in,  and  death  follows  within  a  few  days.  Some 
cases  show  symptoms  belonging  to  both  these  classes.  It  is  important 
to  remember  that  mad  dogs  show  no  fear  of  water  and  are  able  to  eat 
and  drink  until  paralysis  of  the  throat  sets  in.  This  is  sometimes  early 
in  the  disease,  as  in  the  dumb  form.  In  other  cases  it  may  not  occur 
until  just  before  death. 

"  It  should  be  remembered  also  that  the  secretions  from  the  mouth  of 
the  rabid  dog  are  poisonous  whether  he  shows  any  tendency  to  bite  or  not. 

"  The  only  safe  rule  to  follow  is  to  be  careful  in  handling  anj'  sick 
dog  until  absolutely  sure  that  he  has  not  rabies,  to  wear  heax'y  gloves 
in  handling  such  a  dog,  and  to  avoid  the  secretion  from  the  mouth. 

"  In  case  of  infection  from  the  saliva  of  a  dog  suspected  of  rabies, 
the  wound  should  be  washed  out  at  once  and  a  physician  consulted  as 
soon  as  possible. 

"  If  a  dog  is  sick  with  an  unknown  disease  or  is  suspected  of  being 
rabid  he  should  be  securely  chained  (if  this  can  be  done  without  undue 
risk)  and  the  Board  of  Health  notified.  If  a  dog  suspected  of  being 
rabid  is  running  wild  and  biting  persons  he  should  be  killed  as  quickly 
as  possible  and  the  carcass  held  for  examination  by  the  Board  of  Health." 
(Adapted  from  form  used  in  Orange,  N.  J.) 

The  Massachusetts  law  prescribes  that  "  every^  license  issued  to  the 
owner  of  a  dog  shall  have  a  description  of  the  symptoms  of  hydro- 
phobia printed  thereon,"  such  description  to  be  supplied  to  the  local 
authorities  by  the  state  health  department. 


226  A   MANUAL   FOR   HEALTH   OFFICERS 

disease,  and  inculcation  of  such  knowledge  would  prevent 
many  if  not  most  of  the  cases  of  bites  by  ral)id  animals. 

4.  Legal  Responsibility  of  Doc;-()\vners.  —  The 
owners  of  (loj;s  should  Ix'  made  legally  and  explicitly  re- 
sponsible for  any  and  all  damage  inflicted  by  their  dogs.^ 
This  would  include  the  cost  of  the  Pasteur  treatment  taken 
by  persons  bitten  by  a  rabid  or  supposedly  rabid  dog. 

The  iTieasures  to  be  taken  by  the  health  authorities  in 
specific  cases  are  as  follows: 

I .  Reporting  of  Dog-Bites.  —  Every  case  of  a  person 
bitten  by  a  dog  should  be  reported  to  the  local  health 
office  by  any  person  having  cognizance  of  the  fact.  This 
would  api^ly  particularly  to  physicians  called  upon  to  treat 
wounds,'-  and  to  the  police,  who  are  frequently  appealed  to 
in  such  cases.  The  majority  of  persons  bitten  are  children, 
and  there  is  danger  that  some  of  these  cases  will  go  unre- 
ported unless  public  attention  is  called  to  the  necessity  of 
reporting  even  minor  bites  by  animals.  The  health  au- 
thorities should  locate  the  dog,  order  it  (if  possible  without 
danger  to  persons)  to  be  secured  with  a  chain  (not  a  rope, 
which  may  be  chewed  through  by  the  animal)  or  penned  up, 
and  kept  from  the  access  of  children  and  other  persons  for 
ten  days.  In  some  instances  it  may  be  advisable  to  re- 
move the  animal  to  the  pound  or  some  other  place  where 
a  good  surveillance  can  be  maintained.  Careful  inquiry 
should  be  made  to  obtain  the  names  and  addresses  of  all 

'  Such  a  law  has  been  adopted  in  Ohio.     See  note,  p.  232. 

^  "  Wounds  produced  by  the  bite  of  an  animal  in  which  there  is 
any  suspicion  of  rabies  should  at  once  be  cauterized  with  fuming  nitric- 
acid.  The  acid  is  best  applied  with  a  glass  rod  very  thoroughly  to  all 
parts  of  the  wound,  care  being  taken  that  pockets  and  recesses  do  not 
escape.  Thorough  cauterization  at  once  reduces  the  danger  of  wound 
complications,  and  experience  demonstrates  that  wounds  so  treated  at 
once,  are  practically  never  followed  by  rabies.  ...  In  the  absence  of 
nitric-acid  the  actual  cautery  may  be  used.  ...  In  any  wound  pro- 
duced by  the  bite  of  an  animal  the  rule  is  to  cauterize  unless  sure  that 
the  animal  is  not  mad."  (Rosenau,  "  Preventive  Medicine  and  Hy- 
giene," 1913,  p.  40  f.) 


COMMUNICABLE  DISEASE  227 

persons  who  may  have  been  bitlcn.  The  do^  should  not 
be  killed  unless  necessary  for  safety. 

If  it  is  necessary  to  kill  the  dog,  or  if  it  dies  while  under 
observation,  the  carcass  or  head  must  be  sent  to  the  labo- 
ratory for  examination  (see  page  222).  A  great  many  cases 
of  dog-bite  occur  in  which  the  animal  is  not  rabid,  but  the 
above  precautions  should  always  be  taken  if  any  persons 
have  been  bitten. 

Dogs,  not  rabid,  which  are  so  vicious  as  to  be  unsafe  at 
large  should  be  dealt  with  by  police  regulations  requiring 
them  to  be  penned  up  or  chained. 

If  the  animal  lives  until  the  expiration  of  the  surveillance 
period,  no  further  action  need  be  taken. 

But  if  a  positive  diagnosis  of  rabies  is  made  or  if  the  animal 
dies  or  is  killed  with  suspicious  symptoms  (even  if  the 
laboratory  test^  turns  out  negative),  then  immediate  action 
is  to  be  taken  as  follows: 

(a)  The  persons  who  have  been  bitten  should  take  the 
Pasteur  preventive  treatment.^  Great  pains  should  be 
taken  to  locate  all  persons  who  have  been  bitten  by  the 
animal  and  to  obtain  an  exact  account  of  the  circumstances 
in  the  various  cases.  (If  the  animal  has  run  in  from  another 
community  the  health  ofificer  of  that  community  should  be 
notified.)  It  is  the  duty  of  the  health  ofificer  to  urge  the 
treatment  in  all  positive  cases  and  advise  it  in  all  doubtful 
ones.  If  the  person  has  not  been  actually  bitten  but  has 
had  the  face  or  hands  licked  by  a  dog  which  subsequently 
was  proved  rabid,  he  may  be  told  that  the  danger  is  slight 
but  that  to  be  on  the  safe  side  the  treatment  may  be  taken. 
On  the  other  hand,  there  is  trouble  and  expense  (as  well  as 
a  slight  danger  of  paralysis  as  a  complication)  connected 

^  Reference  is  to  the  examination  for  Negri  bodies,  which  can  be 
made  without  delay.     Animal  inoculations  take  longer.     See  p.  222. 

^  The  treatment  is  generally  furnished  by  state  and  large  municipal 
laboratories,  and  by  several  commercial  manufacturers.  The  doses 
may  be  sent  to  a  distance  and  administered  by  a  local  physician. 


228  A  MANUAL  FOR  HEALTH  OFFICERS 

with  Pasteur  treatment  and  it  should  therefore  not  be  ad- 
vised indiscriminately. 

The  treatment  reduces  the  mortality  in  persons  bitten 
by  rabid  dogs  to  0.5  per  cent  or  less.  Since  immunity  can 
be  produced  by  the  Pasteur  treatment  within  a  consider- 
ably shorter  time  than  the  incubation  period  of  rabies,  it  is 
evident  that  if  the  treatment  is  started  early  it  is  a  highly 
effective  measure  of  protection. 

The  question  of  expense  not  infrequently  arises.  Poor 
persons  are  unable  to  pay  the  cost  of  the  treatment,  and 
cases  are  not  unknown  where  lives  have  been  lost  through 
omission  on  this  account.  There  should  be  no  hesitation 
whatever  in  so  serious  a  matter.  Provision  should  be  made 
by  law  that  the  expenses  of  treatment  for  persons  unable  to 
pay  should  be  paid  out  of  the  community  poor  funds. 
Delay  and  red  tape  should  be  obviated  so  that  no  person 
need  hesitate  on  account  of  the  expense  or  the  question 
who  is  to  defray  it.  The  owner  of  the  rabid  animal  should 
ultimately  be  liable  for  such  expenses,  which  may  be 
recovered  later,  after  the  treatment  has  been  begun. 

{h)  The  animals  which  have  been  bitten  (or  are  suspected 
of  having  been  bitten)  should  be  killed  by  the  owner  at  the 
direction  of  the  health  officer.  (It  is  assumed  that  care 
has  been  taken  to  get  a  complete  list  of  such  animals.) 
Most  owners  can  be  persuaded  to  destroy  their  dogs  if 
they  are  told  that  there  is  a  strong  possibility  of  rabies 
developing.  Valuable  animals  may  as  an  alternative  be 
kept  under  strict  surveillance,  confined  and  subject  to  in- 
spection by  the  health  authorities  for  six  months.  Such 
confinement  requires  the  animal  to  be  secured  with  a  metal 
chain  or  to  be  kept  in  a  secure  pen  away  from  access  of 
persons.  The  owner  must  immediately  report  any  un- 
usual behavior  or  symptoms  of  the  dog,  and  if  it  develops 
rabies  it  must  at  once  be  destroyed  and  the  kennel  or  pen 
disinfected.  Such  quarantines  are  usually  difficult  to  keep, 
for  the  animal  becomes  restive  and  may  be  surreptitiously 


COMMUNICABLE  DISEASE  229 

taken  out  for  an  airinj^.  They  should  only  be  resorted  to 
exceptionally;  there  slK)uld  be  careful  oversight  anc]  any 
infringement  should  be  at  once  prosecuted.  It  is  desirable 
that  the  health  authorities  have  power  conferred  by  law  to 
kill  such  animals  if  the  quarantine  be  not  satisfactorily  kept. 

The  cooperation  of  the  police  must  be  secured,  for  upon 
them  the  health  authorities  must  rely  for  a  great  deal  of 
information  and  support. 

2.  Rabies  (or  Suspected  Rabies)  in  Animals  to  be 
Reported. —  This  requirement  applies  particularly  to  dogs. 
Every  person  having  custody  of  a  dog  should  report  at  once 
to  the  health  authorities  any  suspicious  symptoms  (see  sec.  I 
of  the  ordinance  in  footnote  below).  Through  effective 
education  of  dog-owners  it  should  be  possible  to  enforce 
such  a  requirement.  An  inspector  may  see  the  animal  and 
if  necessary  call  in  a  veterinarian  or  take  other  steps  to 
establish  a  diagnosis  (see  page  222).  If  no  persons  have 
been  bitten  and  the  symptoms  are  very  suspicious  of  rabies 
the  animal  should  be  killed.  The  carcass  should  be  dis- 
posed of  with  care,  and  the  kennel  or  pen  should  be  de- 
stroyed or  disinfected.  The  steps  to  be  taken  when  persons 
or  other  animals  have  been  bitten  have  already  been 
described.^ 

^  The  following  may  serve  as  an  example  of  an  ordinance  covering 
most  of  the  points  mentioned  In  these  two  sections.  Such  provisions, 
as  will  be  explained  presently,  should  be  enacted  in  state  law. 

"  I.  Whenever  the  owner  or  person  having  the  custody  or  possession 
of  any  animal  shall  observe  or  learn  that  such  animal  has  shown  symp- 
toms of  rabies,  or  has  acted  in  a  manner  which  would  lead  a  reasonable 
man  to  a  suspicion  that  it  might  have  rabies,  such  owner  or  person 
having  the  custody  or  possession  of  such  animal  shall  immediately 
notify  the  Board  of  Health  or  the  Health  Officer,  and  shall  allow  the 
Health  Officer  or  other  official  of  the  Board  of  Health  to  make  an  in- 
spection or  examination  of  such  animal,  and  to  quarantine  such  animal 
until  it  shall  be  established  to  the  satisfaction  of  said  official  that  such 
animal  has  or  has  not  rabies. 

"2.  Whenever  it  is  shown  that  any  dog  has  bitten  any  person, 
the  owner  or  person  having  the  custody  or  possession  thereof  shall, 


230  A  MANUAL  FOR   HEALTH  OFFICERS 

Needless  to  say,  reporting  of  rabies  in  human  subjects 
should  be  required. 

3.  Power  to  Declare  Quarantine.  —  Where  an  epizo- 
otic outbreak  of  rabies  exists  or  threatens,  the  local  health 
authorities  should  have  the  power  to  declare  a  quarantine 
of  dogs  in  the  district  under  its  jurisdiction.  Such  quaran- 
tine may  require  restriction  of  dogs  to  premises,  or  leashing 
or  muzzling.  It  must  be  strictly  enforced  by  alert  inspec- 
tors or  dog-wardens,  with  the  power  to  take  up  the  dogs  in 
cases  where  the  order  is  not  complied  with  and  to  hold  them 
until  a  fine  is  paid  or  to  destroy  them  if  not  claimed. 
While  quarantines  are  frequently  a  matter  for  areas  larger 
than  local  municipalities,  such  local  quarantines  have  a 
certain  value. 

upon  order  of  the  Health  Officer,  quarantine  it  and  keep  it  tied  up  or 
confined  for  a  period  of  two  weeks  [10  days  sufficient  —  Author]  and 
shall  allow  the  Health  Officer  or  other  official  of  the  Board  of  Health  to 
make  an  inspection  or  examination  thereof  at  any  time  during  said 
period. 

"  3.  If  it  shall  appear  to  the  Health  Officer  or  other  official  of  the 
Board  of  Health  upon  examination  as  aforesaid,  or  otherwise  that  a  dog 
or  other  animal  has  rabies,  he  may  kill  it  forthwith. 

"  4.  Whenever  any  animal  shall  be  bitten  by  another  animal  having 
rabies,  the  owner  or  person  having  the  custody  or  possession  of  the 
animal  so  bitten  shall,  upon  being  informed  thereof,  either  kill  such 
animal  or  quarantine  it  and  keep  it  tied  up  or  confined  for  a  period  of  six 
months,  and  the  Health  Officer  or  other  official  of  the  Board  of  Health 
shall  have  power,  in  his  discretion,  to  kill  or  quarantine  the  animal  so 
bitten,  in  case  the  owner  or  person  having  the  custody  or  possession 
thereof  shall  fail  to  do  so  immediately,  or  in  case  the  owner  or  person 
having  the  custody  thereof  is  not  readily  accessible. 

"  5.  Any  person  violating  any  one  of  the  provisions  of  this  ordinance 
shall  forfeit  and  pay  a  penalty  of  twenty-five  dollars  for  each  offence." 
(Ordinance  of  Orange,  N.  J.,  Board  of  Health.) 

(Note  that  the  general  term  "  animal  "  is  used  in  sees,  i,  3,  and  4. 
Laws  should  be  so  worded  in  order  that  measures  usually  applicable 
to  rabies  in  dogs  may  by  extension  be  applied  to  the  occasional  occur- 
rence of  rabies  in  other  animals.) 

Other  provisions,  e.g.,  power  to  declare  quarantine,  etc.,  as  suggested 
in  the  discussion,  should  be  incorporated  in  state  or  local  law. 


COMMUNiCAI'.IJ';    DISKASK  2.31 

The  quesUon  of  the  control  of  simply  vicious  flogs  is  re- 
lated to  public  safety  rather  than  public  health  and  can- 
not be  taken  up  here.  It  may  be  dealt  with  by  police 
ordinances. 

Necessity  for  State-wide  Control.  —  Notwithstand- 
ing that  a  local  health  department  may  wield  all  the  powers 
mentioned  above,  the  rabies  problem  is  by  no  means  en- 
tirely solved.  It  is  a  matter  demanding  also  slate  and 
federal  control.  The  reason  for  this  is  that,  no  matter  how 
strictly  local  regulations  may  be  enforced,  a  single  com- 
munity is  always  at  the  mercy  of  the  rabid  dogs  which  may 
enter  it  from  neighboring  communities.  Rabies  occurs 
very  frequently  in  the  wandering  dog  —  the  stray  without 
care  or  restraint.  Such  dogs,  driven  by  the  restlessness  or 
frenzy  characteristic  of  the  disease,  frequently  travel  many 
miles.  In  their  journey  they  may  pass  through  several 
towns,  biting  and  infecting  persons  and  animals  as  they 
go.  Every  health  officer  of  experience  knows  that  this  is 
not  an  uncommon  experience.  Sometimes  children  are 
"nipped"  by  such  an  animal,  which  then  disappears;  and 
the  incident  is  lightly  passed  over  and  forgotten  until, 
several  weeks  later,  cases  of  rabies  develop  in  human  sub- 
jects and  dogs.  The  dangers  are  too  obvious  to  require 
elaboration.  The  question  is,  how  can  a  community  pro- 
tect itself  from  such  occurrences?  We  are  forced  to 
answer,  it  cannot.  There  should  be  general  enforcement 
of  uniform  law  throughout  the  state,  state  authorities 
should  have  power  to  declare  regional  quarantines  and 
other  measures,  and  all  states  should  cooperate  in  action.^ 

1  Several  states  have  now  some  measure  of  control.  "Massa- 
chusetts has  an  admirable  law.  Every  city  and  town  is  required  by 
law  to  have  an  inspector  of  animals  who  is  responsible  to  the  State 
Cattle  Bureau,  and  who  has,  as  one  of  his  duties,  the  killing  or  quar- 
antining of  animals  exposed  to  rabies.  As  a  result  of  this  law  there 
has  been  a  remarkable  decrease  in  rabies  during  the  past  year.  .  .  . 
New  York  has  a  law  which  gives  the  right  to  the  State  to  enforce  quar- 
antine and  muzzling  of  dogs  where  necessary.  .  .  .     Pennsylvania  has  a 


232  A  MANUAL  FOR  HEALTH  OFFICERS 

Ultimately  there  should  be  federal  quarantine  restrictions 
on  the  importation  of  dogs,  which,  combined  with  muzzling 
until  rabies  shall  have  disappeared,  would  completely  ex- 
tirpate the  disease  (see  page  223), 

State  legislation  should  cover  the  whole  subject  in  detail 
and  might  well  embody  the  following  points,  as  a  summary 
of  what  has  been  said:  (i)  Registration  (licensing)  of  all 
dogs,  (2)  Information  to  dog  owners,  (3)  Legal  responsi- 
bility of  dog  owners,  (4)  Free  treatment  of  indigent  per- 
sons bitten  by  rabid  animals,  (5)  Reporting  of  all  dog- 
bites,  (6)  Reporting  of  rabies  or  suspected  rabies  in  beast 
or  man,  (7)  Surveillance  of  animals,  local  or  district 
quarantine,  muzzling,  etc.,  under  control  of  local  or  state 
authorities,  as  circumstances  may  require.  Some  of  these 
provisions  would  be  left  to  local  authorities  for  execution, 
with  power  of  supervision  by  state  authorities  and  of  inter- 
vention by  them  in  case  local  action  is  inadequate. 

similar  law,  and  also  provides  a  fund  for  reimbursing  persons  whose 
cattle,  horses,  sheep,  or  swine  may  be  killed  by  reason  of  their  having 
been  bitten  by  rabid  dogs.  Pennsylvania  also  provides  free  treatment 
for  all  persons  exposed  to  rabies  from  any  animal  at  the  expense  of  the 
poor  district  of  the  county.  ...  In  Ohio,  dog  owners  are  liable  for 
damages  done  by  their  dogs.  County  commissioners  may  pay  the 
whole  or  part  of  the  expenses  incurred  by  a  person  in  undergoing  treat- 
ment for  the  bite  of  a  rabid  animal.  .  .  .  District  of  Columbia  has  a 
general  muzzling  law  of  all  dogs,  which  went  into  effect  August  11, 
19 10.  This  ordinance  has  just  been  renewed  for  another  year.  The 
effect  of  the  general  muzzling  law  has  caused  a  marked  reduction  in 
the  number  of  cases  of  rabies."  (Hallett,  F.  S.,  "  Rabies:  Its  Preven- 
tion and  Control,"  Proceedings  of  Third  Annual  Conference  of  Stale 
and  Local  Boards  of  Health  of  New  Jersey,  1912.)  In  Connecticut 
cases  of  animal  rabies  are  reported  by  health  officers  to  the  State  Com- 
missioner on  Domestic  Animals,  who  has  authority  to  take  charge  of 
the  situation  and  make  any  necessary  regulations  concerning  dogs. 
An  Act  of  1909  also  provides  that  when  a  licensed  physician  certifies 
to  the  selectmen  of  the  town  in  which  the  injury  was  received  that 
Pasteur  treatment  is  necessary,  they  shall  bear  the  expense  of  such 
treatment. 


COMMUNICABLE   DISEASE  233 

In  conclusion  it  may  be  said  that,  in  the  adoption  of  [pro- 
visions for  the  control  of  rabies,  health  authorities  will 
meet  with  a  good  deal  of  well-intentioned  l)ut  erroneous 
opposition  on  the  part  of  "dog-lovers."  Such  opposition 
may  be  met  with  tact  in  stating  that  rabies  cannot  be 
stamped  out  except  by  strict  measures  of  control  extending 
over  some  years  and  that  the  safety  of  man  outweighs 
restrictions  on  the  comfort  of  the  animal.  Furthermore, 
the  suppression  of  rabies  benefits  the  animals  themselves 
and  results  in  a  considerable  saving  in  live-stock.  A  well- 
informed  general  public  opinion,  both  of  those  who  own 
dogs  and  of  those  who  do  not,  should  support  effective 
measures  for  the  control  of  this  dread  but  wholly  prevent- 
able disease. 

REFERENCES 

Bull.  no.  65,  Hyg.  Lab.  U.  S.  Pub.  Health  Service. 

Farmers  Bull.  no.  449,  Dept.  of  Agriculture. 

Papers  by  Albert  and  Cumming  in  Transactions  of  the  XV  Inter- 
national Congress  on  Hygiene  and  Demography,  1912,  vol.  IV,  pt.  I, 
Govt.  Printing  Office,  Washington,  1913. 


VENEREAL  DISEASE 

The  venereal  diseases  are  now  considered  as  one  of  the 
major  problems  in  communicable  disease.  But  thus  far 
the  steps  made  toward  treating  venereal  disease  as  a  public 
health  problem  have  been  limited,  the  reason  being  that 
it  is  so  deeply  rooted  in  private  life  and  so  closely  inter- 
woven with  the  passions  and  morals  of  the  individual. 
The  fact  that  knowledge  of  the  modes  and  chances  of  in- 
fection fails  to  deter  many  persons  from  exposure  to  the 
risk  of  contracting  these  loathsome  diseases  indicates  the 
force  behind  their  propagation. 

The  two  chief  diseases  under  this  head  are  syphilis 
(cause:    a  protozoon,  the  Treponema  pallidum)  and  gonor- 


234  A  MANUAL   FOR   HEALTH  OFFICERS 

rhoea  (cause:    the  Gonococcus).     To  these  we  may  add,  as 
secondary,  though  important,  chancroid. 

Transmission.  —  While  venereal  transmission  of  these 
diseases  is  the  common  mode,  transmission  also  takes  place 
by  other  modes  of  contact.  Thus  syphilis  may  be  trans- 
mitted through  kissing  and  by  towels,  cups,  eating  utensils, 
barbers'  implements  and  other  objects,  in  such  manner 
that  the  mucous  membrane  of  the  mouth,  lips,  etc.,  or  skin 
abrasions,  become  infected.  Again,  gonorrhoea,  especially 
in  the  form  of  gonorrhoeal  inflammation  of  the  eye,  is  com- 
municable by  means  of  infected  towels,  toilet  fixtures,  etc. 
Thus  innocent  persons  contract  the  infections  more  fre- 
quently than  is  commonly  supposed.  The  largest  class  of 
the  innocently  infected  consists  of  women  who  are  infected 
by  their  husbands.  It  has  been  stated  that  the  greater 
part  of  the  cases  in  the  practice  of  gynecology,  including 
operations  for  diseases  of  the  female  genital  system,  are 
the  result  of  gonorrheal  infection.  Still  another  rrianifesta- 
tion  of  gonorrhoeal  infection  is  gonorrhoeal  ophthalmia 
neonatorum  (see  below,  "Preventable  Blindness").  Alto-^ 
gether,  gonorrhoea,  while  popularly  regarded  as  a  trivial 
infection,  "is  one  of  the  serious  infectious  diseases,  and  the 
gonococcus  occupies  a  position  of  high  rank  among  the 
virulent  pathogenic  microorganisms.  From  an  economic 
and  public  health  standpoint,  gonorrhoea  does  not  fall  very 
far  short  of  syphilis  in  importance;  in  fact,  some  give  it 
the  first  place."     (Rosenau.) 

The  prophylaxis  to  be  observed  by  the  patient  includes 
not  only  abstention  from  venereal  transmission,  but  also 
measures  to  avoid  contact  infection  of  innocent  persons  by 
the  means  already  suggested.  Such  measures  include 
personal  cleanliness,  careful  washing  and  disinfection  of 
the  hands,  the  use  of  individual  towels,  cups,  glasses,  etc., 
as  long  as  there  are  discharges  or  open  lesions.  The  clean- 
liness and  disinfection  of  privy  and  water-closet  seats  and 
other  toilet  fixtures  should  be  looked  after. 


COMMUNICAI'.IJ';    DISIOASIC  235 

Incidence.  —  Reliable  statistics  of  venereal  flisease  are 
at  the  present  time  scanty,  and  estimates  should  be  taken 
with  caution.  Even  the  deaths  are  rarely  ascril;ed  f)ri- 
marily  to  syphilis  or  gonorrhcjca,  but  to  some  terminal 
condition,  which  is  either  the  only  thing  the  physician 
perceives  or  the  only  thing  considered  sufficiently  euphe- 
mistic to  inscribe  on  a  public  record  of  death.  However, 
the  direct  mortality  is  not  the  only,  nor  the  worst,  effect 
of  these  diseases;  most  of  the  damage  is  insidious,  elusive 
and  indirect. 

In  the  absence  of  public  statistics  we  turn  to  hospital  and 
medical  records,  the  revelations  of  which  can,  however, 
be  only  briefly  alluded  to  here.  The  end-results  of  syphilis 
in  the  patient  may  be  general  paresis,  arteriosclerosis, 
locomotor  ataxia,  aneurysm,  etc.  The  disease  also  tends 
strongly  to  produce  susceptibility  to  tuberculosis  and  other 
infections  and  diseases.  The  effect  on  the  offspring  may 
be  even  more  severe.  To  hereditary  syphilis  are  due  many 
deaths  of  infants  put  down  to  congenital  malformation, 
congenital  debility,  and  the  like;  while  infants  who  sur- 
vive are  blighted  with  various  impairments  and  affections. 
Gonorrhoea  is  remarkable  for  the  multiplicity  of  its  forms 
of  infection  and  for  its  long  persistence.  Gonorrhoeal 
arthritis  and  sterility  are  among  the  more  serious  develop- 
ments. Its  effects  in  the  female  system  have  already  been 
alluded  to.  The  thorough  cure  of  gonorrhoea  is  a  difficult 
matter;  the  infection  may  persist  for  years.  In  children's 
hospitals  gonorrhoeal  infection  may  become  epidemic, 
constituting  an  obstinate  problem. 

Control.  —  From  the  sanitary  standpoint  the  venereal 
diseases  should  be  subject  to  the  same  sort  of  control  as 
other  serious  communicable  diseases  which  require  certain 
restrictions  to  be  laid  on  the  infectious  person.  Practically, 
however,  the  connection  of  the  diseases  wath  the  deeply 
rooted  "social  evil"  and  its  intrenchment  behind  the  walls 
of  private  life  have  stood  as  an  obstacle  to  the  adminis- 


236  A  MANUAL   FOR   HEALTH   OFFICERS 

trative  measures  which  would  otherwise  be  taken.  We 
shall  briefly  outline  the  measures  thus  far  proposed.  It 
scarcely  need  be  said  that  health  authorities  can  only 
undertake  to  deal  with  the  purely  sanitary  features  of  the 
problem. 

1.  Registration  of  Cases.  —  The  logical  first  step  is 
to  obtain  knowledge  of  the  problem  through  reports  from 
physicians.  Voluntary  reporting  alone  will  not  accom- 
plish much,  but  procedure  may  be  taken,  as  has  been  done 
in  New  York  City,  by  progressive  steps:  first,  voluntary 
reporting  by  physicians  of  their  private  cases,  with  the 
understanding  that  the  data  are  merely  to  gain  knowledge 
of  prevalence,  and  obligatory  reporting  of  cases  treated  in 
hospitals  and  dispensaries;  eventually,  obligatory  report- 
ing of  all  cases.^  As  a  concession  to  privacy,  the  reports 
may  —  at  first,  at  any  rate  —  be  made  under  numbers 
indicated  by  the  physicians  instead  of  by  name.  There 
are  indications  that  eventually  a  complete  registration  of 
the  venereal  diseases  may  be  built  up. 

2.  Laboratory  Diagnosis.  —  It  is  highly  important 
that  the  health  department  afTord  laboratory  diagnosis. 
The  following  tests  are  available:  for  syphilis,  the  Wasser- 
mann  serum  reaction  and  the  microscopic  examination  for 
the  treponemal  for  gonorrhoea,  the  complement  fixation 
test  and  the  microscopic  examination  for  the  gonococcus. 
Such  examinations  should  at  least  be  made  free  of  charge 
by  state  laboratories  as  they  are  now  made  in  several  of 
the  larger  cities,  on  condition  that  full  information  (in- 
cluding name)  of  the  case  be  furnished  by  the  physician. 

1  In  Montclair,  N.  J.,  hospitals,  dispensaries  and  other  institutions 
are  required  to  report  cases  of  venereal  disease  within  twelve  hours,  and 
private  physicians  are  requested  to  do  so.  Information  is  confidential 
and  records  are  not  open  to  the  public.  The  health  department  makes 
free  laboratory  tests  for  diagnosis,  requires  treatment  (alternative, 
isolation),  and  provides  treatment  free  of  charge  for  indigent  cases. 
Venereal  diseases  are  also  reportable  in  California,  Michigan  and 
Vermont. 


COMMUNICAIiLI')    DISIIASK  237 

3.  SuriCRVisioN  OF  CasI':s.  —  When  a  resist  rat  i(Hi  of 
cases  has  been  secured  it  is  the  next  logical  step  to  insure 
as  far  as  practicable  that  each  case  is  prevented  from  ex- 
tending infection.  The  chief  object  is  to  prevent  the 
infection  of  innocent  persons  in  the  ways  which  have  al- 
ready been  mentioned. 

For  cases  under  the  care  of  a  private  physiciaft  the  in- 
struction of  the  patient  as  to  the  dangers  of  spreading  the 
infection  and  the  precautions  to  be  observed  should  be 
attended  to  by  the  physician.  It  is  evident  that  the  con- 
trol over  private  cases  must  be  secured  through  the  physi- 
cian and  with  his  cooperation.  The  emphasis  in  treatment, 
from  the  public  health  standpoint,  should  be  placed  upon 
freeing  the  patient  from  infection  as  well  as  merely  abating 
painful  symptoms.  Many  cases  unfortunately  leave  the 
physician's  care  before  that  end  is  attained,  and,  while 
control  of  them  is  lost,  remain  sources  of  infection. 

In  regard  to  hospitals  and  dispensaries,  efforts  should  be 
made  to  increase  the  facilities  for  treatment.  Such  treat- 
ment, from  the  standpoint  of  the  sanitary  authorities, 
should  be  directed  toward  rendering  the  patient  non-infectious. 
Many  patients  obtain  the  cheapest  possible  medical  treat- 
ment and  leave  off  as  soon  as  acute  symptoms  subside, 
but  while  they  are  still  infective.  Again,  other  cases,  self- 
treated,  never  see  a  doctor.  Thus  there  is  a  class  of  per- 
sons who,  apparently  healthy  but  really  dangerous,  are 
virtually  carriers  of  venereal  disease.  There  should  be 
some  way  of  securing  the  continued  treatment  of  such  until 
they  are  completely  cured  and  non-infective.  Many 
hospitals  refuse  patients  with  acute  venereal  disease,  yet 
the  public  health  requires  adequate  hospital  treatment. 
Genito-urinary  clinics  are  needed  in  places  where  they  do 
not  now  exist.  The  aim  of  the  health  authorities  should 
be  eventually  to  enforce  the  treatment  of  all  venereal 
cases  —  private,  dispensary,  and  hospital  —  until  they  are 
rendered  non-infective,  and  to  keep  them  until  that  time 


238  A   MANUAL   rOR    HKALTH   OFFICERS 

under  supervision   with    the   requirement   of   prophylactic 
measures  for  the  protection  of  other  persons.^ 

It  may  be  added  that  the  measure  of  regulating  prosti- 
tution through  medical  inspection  and  licensing  of  prosti- 
tutes, which  has  frequently  been  tried  in  European  cities, 
has  been  largely  abandoned;  partly  because  it  tends  to 
defeat  its  own  object  by  making  vice  safer  and  partly 
because  it  involves  an  ofificial  recognition  and  condoning 
of  vice,  but  chiefly  because  it  does  not  reach  —  but  rather 
increases  —  the  clandestine  prostitution  which  is  the  great- 
est source  of  venereal  disease.  Even  where  such  regula- 
tion is  practiced,  medical  inspection  is  far  from  being  a 
complete  safeguard. 

Other  proposals  need  not  be  considered  here.  Some, 
such  as  the  formal  teaching  of  so-called  sex  hygiene,  may 
be  condemned  on  moral  as  well  as  practical  grounds.  The 
same  may  be  said  of  publicity  on  this  class  of  subjects. 

In  fine,  it  may  be  said  that  the  control  of  venereal  dis- 
ease—  the  "black  plague" — while  a  public  health  prob- 
lem, is  also  —  and  fundamentally  —  a  social  and  moral 
problem  closely  interwoven  with  alcoholism  and  other 
evils.  There  is  at  the  present  time  a  movement  against 
the  social  evil,  which  has  given  rise  to  many  unsound  pro- 
posals, as  well  as  to  some  good  ones,  —  a  situation  which 
calls  for  careful  discrimination. 

REFERENCES 

Bolduan,  "  Venereal  Diseases  —  The  Relation  of  the  Public  Health 
Authorities  to  their  Control,"  Am.  Jour.  Pub.  Health,  1913,  vol.  Ill, 
no.  ID,  p.  1087. 

Reports  of  Committee  of  American  Public  Health  Association. 

'  The  Board  of  Health  of  Montclair,  N.  J.,  has  recently  adopted  the 
following  regulation: 

"  Every  person  residing  in  or  working  in  the  Town  of  Montclair  who 
is  found  to  be  affected  with  a  venereal  disease  shall  immediately  take 
proper  treatment  for  the  cure  of  such  disease,  or  be  isolated." 


COMMUNICABLE  DISEASE  239 

PREVENTABLE   BLINDNESS 

OPHTHALMIA    NEON  A  TOR  UM 

Ophthalmia  neonatorum  is  a  term  covering  all  inflamma- 
tions of  the  eyes  of  newborn  infants.  Such  inflammations 
are  accompanied  by  more  or  less  discharge  and  destruction 
of  tissue  and  may  cause  permanent  and  needless  blindness. 
In  this,  gonorrhceal  infection  at  time  of  birth  is  the  largest 
single  factor.  There  are  also  other  causes  of  preventable 
blindness  —  e.g.,  various  infections,  trachoma,  poisonings 
(wood  alcohol,  excessive  use  of  alcohol  or  tobacco,  lead, 
etc.),  accidental  injuries,  etc.  —  but  the  following  discus- 
sion will  be  limited  to  the  chief  preventable  cause:  ophthal- 
mia neonatorum.  A  few  remarks  will  also  be  devoted  to 
trachoma. 

There  are  64,000  registered  blind  persons  in  the  United  States.  Of 
these  about  10  per  cent  (between  six  and  seven  thousand)  are  blind  as 
the  result  of  ophthalmia  neonatorum.  From  25  to  30  per  cent  of  all  the 
blind  children  in  all  the  blind  schools  of  this  country  owe  their  affliction 
to  gonorrhoea.  It  has  been  estimated  that  probably  one-half  of  the 
blindness  in  the  world  is  preventable.' 

There  are  no  complete  statistics  on  ophthalmia  neona- 
torum. It  has,  however,  been  ascertained  through  figures 
collected  from  physicians  that  it  may  occur  in  eleven  cases 
per  thousand  births. ^ 

Transmission.  —  Ophthalmia  neonatorum  at  time  of 
birth  is  usually  a  gonorrhceal  infection  contracted  from  the 
mother.  Gonorrhceal  and  other  infection  after  birth  may 
also  take  place  through  contact  of  infected  hands,  towels, 
etc.  If  such  infections  are  permitted  to  develop  and  con- 
tinue the  eyesight  is  always  menaced  and  frequently  de- 
stroyed. 

^  Rosenau,  "  Preventive  Medicine  and  Hygiene,"  1913,  p.  60. 
'  Monograph  Series  of  the  Am.  Assn.  for  Conserv'ation  of  \  ision, 
vol.  I,  no.  I. 


240  A  MANUAL  FOR  HEALTH  OFFICERS 

Control.  —  Ophthalmia  neonatorum  is  absolutely  and 
entirely  preventable.  The  principle  of  control  is  to  dis- 
infect the  eyes  of  all  newborn  infants  by  appropriate 
prophylactic  treatment.  Even  if  the  inflammation  has 
developed  it  may  be  checked  by  proper  treatment. 

The  following  administrative  measures  should  be  adopted : 

I.  Prophylactic  Treatment  of  Eyes  of  the  New- 
born. —  The  law  should  provide  that  at  time  of  birth  the 
eyes  of  all  newborn  infants  be  treated  with  prophylactic 
solution.  The  physician  and  midwife  should  be  relieved 
of  the  uncertainty  and  responsibility  of  deciding  whether 
or  not  the  treatment  is  necessary  in  any  given  case  by  being 
required  to  apply  it  in  all  cases. 

The  treatment  usually  recommended  is  an  application  of 
silver  nitrate  solution   according   to   the   Crede   method.^ 

Health  authorities  should  distribute  without  charge  to 
physicians  and  midwives  small  outfits  of  silver  nitrate  solu- 
tio7i  with  a  glass  rod  or  dropper  and  printed  instructions.^ 

1  This  consists  in  dropping  into  each  eye  of  the  newborn  infant 
immediately  after  labor  a  drop  of  a  i  per  cent  solution  of  silver  nitrate, 
in  such  manner  that  the  solution  comes  in  contact  for  one-half  minute 
or  longer  with  every  portion  of  the  conjunctival  sac.  Crede's  original 
method  called  for  a  2  per  cent  solution,  but  this  is  apt  to  be  irritating 
and  the  i  per  cent  solutign  for  routine  use  appears  to  afford  adequate 
prophylaxis.  Other  silver  compounds,  such  as  argyrol  (20  to  25  per 
cent),  protargol  (5  to  10  per  cent),  or  sophol  (5  per  cent),  are  said  to  be 
as  effective  as  silver  nitrate  and  less  irritating.  A  second  application 
should  never  be  made  during  the  following  twenty-four  or  thirty-six 
hours,  even  if  slight  redness  and  swelling  of  the  eyelids  with  mucous 
secretion  should  follow  the  first  application;  repeated  applications  may 
cause  serious  inflammation  ("  silver  catarrh  "). 

The  solution  is  kept  in  a  dark-colored  vial  with  ground  glass  stopper, 
having  a  neck  about  half  an  inch  in  diameter.  For  the  dropping  may 
be  used  a  dropper  and  bulb  or  a  glass  rod  about  six  inches  long  and  very 
smooth  and  round  at  each  end.  The  silver  solution  will  keep  for  many 
months,  but  it  is  best  to  renew  it  about  once  in  six  weeks.  Outfits 
should  be  stored  in  a  dark,  cool  place. 

^  Such  prophylactic  outfits,  together  with  a  circular  of  instruction 
in  detail,  are  issued  to  physicians  by  the  health  authorities  of  Massa- 
chusetts, New  Jersey,  Vermont,  Rhode  Island,  New  York,  District 
of  Columbia,  and  other  states. 


COMMUNICAIU-IO    DISICASK  241 

MidwivCvS  require  careful  instruction,  in  most  cases  oral, 
and  should  be  supervised  to  sec  that  they  carry  out  the 
routine  prophylaxis  properly. 

2.  Reporting  of  Eye  Inflammation  in  Infants.  — 
All  cases  of  inflammation  of  the  eyes  of  the  newborn  ap- 
pearing within  one  month  after  birth  should  be  required 
to  be  reported  to  the  health  officer  by  physicians  and  mid- 
wives.  This  requirement  enables  the  health  authorities 
to  ascertain  the  extent  of  the  disease  and  also  to  ensure 
proper  treatment  of  all  cases.  If  the  case  is  under  the  care 
of  a  regular  physician,  no  further  steps  need  be  taken  un- 
less further  information  is  desired.  But  if  it  is  not  known 
that  this  is  the  fact,  the  case  should  at  once  be  looked  up 
to  ascertain  the  nature  of  the  infection  and  what  treatment, 
if  any,  is  being  applied.  Cases  are  sometimes  reported 
by  midwives  in  families  too  poor  to  engage  a  physician; 
such  cases  may  properly  be  referred  at  once  to  the  town 
poor  physician,  who  may  be  assisted  by  the  district  nursing 
association  if  nurse's  services  are  required  in  the  treat- 
ment. 

Diagnosis  of  the  conjunctivitis  should  be  made  without 
delay,  by  microscopic  examination  of  a  stained  smear  of 
the  discharge.  Such  examination  may  be  made  by  the 
health  department  bacteriologist.  The  following  advice 
for  treatment  according  to  the  bacteriological  diagnosis  is 
given  by  Rosenau: 

If  the  inflammation  is  due  to  the  gonococcus,  a  2  per  cent  silver 
nitrate  solution  should  be  used.  In  certain  mild,  non-gonorrha?al 
infection  0.5  per  cent  is  usually  sufficient.  If  the  Klebs-Loefifler  bacillus 
is  found,  diphtheria  antitoxin  should  be  given  without  delay.  If  the 
diplococcus  is  present,  a  weak  solution  (i  grain  to  the  ounce)  of  zinc 
sulphate  should  be  instilled  frequently.^ 

State  Legislation.  —  State  legislation  is  highly  de- 
sirable.^    While  the  aggregate  number  of  cases  constitutes 

^  "  Preventive  Medicine  and  Hygiene,"  1913,  p.  64. 
^  The  following  provisions  of  the  New  Jersey  law  (as  amended  in 
19 10)  may  serve  as  an  example  of  the  character  of  such  legislation: 


242  A   MANUAL   FOR   HEALTH   OFFICERS 

a  serious  problem,  tlic  number  occurring  in  any  one  local 
community  may  escape  observation,  with  the  result  that 
measures  of  control  are  neglected. 

Auxiliary  Measures.  —  The  radical,  but  not  the  most 
direct  and  practicable,  means  of  eliminating  ophthalmia 
neonatorum  is  the  suppression  of  gonorrhoea  as  a  venereal 
disease  (q.v.).  The  education  of  ignorant  midwives  in 
their  duties  regarding  this  disease  (as  "well  as  in  the  general 
technique  of  their  profession)  is  frequently  a  grave  need. 
Finally,  the  prompt  reporting  of  births,  permitting  an 
infant  hygiene  nurse  to  see  infants  shortly  after  birth,  is 
essential. 

TRACHOMA 

Trachoma  is  an  infectious  granulation  of  the  eyelids, 
communicable   by   contact.     It   is   a   chronic    progressive 

1.  "  That  should  one  or  both  eyes  of  an  infant  become  inflamed, 
swollen  or  reddened,  or  show  any  unnatural  discharge  at  any  time 
within  two  weeks  after  its  birth,  and  no  legally-qualified  practitioner  of 
medicine  be  in  attendance  upon  the  infant  at  the  time,  it  shall  be  the 
duty  of  the  midwife,  nurse,  attendant,  or  relative  having  charge  of 
such  infant  to  report  the  fact  in  writing  within  six  hoursf  to  the  local 
board  of  health.  ..." 

2.  Local  board  of  health  to  direct  parents  or  persons  having  charge 
of  such  infant  to  place  it  immediately  in  charge  of  a  legally  qualified 
physician  or  (in  indigent  cases)  of  the  town  physician.  (In  Massa- 
chusetts the  board  of  health  "  shall  take  such  immediate  action  as  it 
may  deem  necessary.") 

3.  Copies  of  law  to  be  printed  by  State  health  authorities  and  sup- 
plied to  local  boards  of  health,  the  latter  to  distribute  a  copy  to  every 
physician,  midwife,  and  nurse  in  their  several  districts. 

4.  Penalty,  $50.  (Provision  should  also  be  made  for  imprisonment 
in  case  fine  is  not  paid.) 

5.  Date  to  take  effect. 

In  Massachusetts,  physicians  as  well  as  midwives,  etc.,  are  required 
to  report  (Revised  Laws,  ch.  75,  sees.  49,  50). 

The  legislation  up  to  191 1  is  summed  up  by  Kerr,  "Ophthalmia 
Neonatorum:  An  Analysis  of  the  Laws  and  Regulations  Relating 
Thereto  in  Force  in  the  LTnited  States,"  Pub.  Health  Bull.  no.  49, 
U.  S.  Pub.  Health  Service,  Oct.,  191 1. 


COMMUNICABLE  DISEASE  243 

disease  which  threatens  vision.  Although  rigidly  excluded 
by  the  immigration  service,  cases  are  not  infrcciucntly 
found  in  the  United  States.  It  should  be  re[)orted  and 
measures  prescribed  by  the  health  authorities  to  prevent 
its  extension.  It  is  favored  by  crowding  and  personal  un- 
cleanliness.  Since  it  is  spread  by  rubbing  the  eyes  with 
infected  towels,  handkerchiefs,  fingers,  etc.,  prophylactic 
measures  consist  in  the  avoidance  of  transferring  infection 
in  such  ways.  Tlie  patient  should  have  his  own  towels, 
handkerchiefs,  washbasin  and  the  like,  and  should  observe 
personal  cleanliness,  avoiding  such  contact  as  might  trans- 
mit the  disease.     It  should  be  excluded  from  schools. 

V.   MISCELLANEOUS    DISEASES 

INFANTILE   PARALYSIS 

Infantile  paralysis  (Acute  anterior  poliomyelitis)  is  an 
acute  infection  of  the  nervous  system  affecting  partic- 
ularly the  spinal  cord.  The  causative  microorganism  is 
as  yet  unknown.  The  disease  is  not  as  yet  well  under- 
stood, but  great  attention  has  been  directed  to  it  in  recent 
years  on  account  of  the  outbreaks  which  have  occurred. 
The  partial  paralysis  from  which  the  disease  is  named  per- 
sists permanently  in  many  cases. 

Transmission.  —  Of  the  following  possible  modes  of 
transmission  (i)  and  (2)  have  thus  far  been  demonstrated: 

I.  Contact.  —  It  is  supposed  that  the  virus  is  discharged 
by  way  of  the  nose  and  mouth  of  the  patient  and  enters 
the  system  of  the  victim  in  the  same  way.  Thus  the 
disease  would  be  spread  in  the  same  way  as  diphtheria  and 
scarlet  fever.  There  is  experimental  evidence  to  support 
this  theory,  though  just  how  much  danger  there  is  in  con- 
tact infection  is  not  at  all  known.  On  the  other  hand,  it 
is  argued  by  epidemiology,  against  the  importance  of  this 
mode  of  transmission:  that  in  actuality  the  disease  does 
not  show  any  noticeable  tendency  to  spread  by  contact, 


244  A  MANUAL   FOR  HEALTH  OFFICERS 

and  tliat  it  does  not  show  a  maximum  incidence  at  the 
same  time  as  diphtheria,  scarlet  fever,  etc.,  which  are 
spread  by  nose  and  throat  secretions. 

2.  Insect  Transmission.  —  In  some  ways  infantile  pa- 
ralysis appears  cpidemiologically  to  be  an  insect-borne 
disease,  and  experiments  have  shown  that  the  virus  may  be 
transmitted  (from  monkey  to  monkey)  by  the  bite  of  the 
stable  fly  (Stomoxys  calcitrans) . 

3.  Other  Modes.  —  Experiment  suggests  that  the  disease 
may  be  conveyed  by  dust.  Food  infection,  inoculation 
through  wounds  and  other  modes  are  possibilities. 

Human  carriers  of  the  disease  have  been  detected,  and 
are  suspected  to  play  an  important  part  in  its  propagation. 

Incidence.  —  Apart  from  greater  recognition,  infantile 
paralysis  has  apparently  been  on  the  increase  in  recent 
years.  In  the  Registration  Area  in  191 1  there  occurred 
1060  deaths,  which  argues  the  existence  of  an  indefinitely 
greater  number  of  cases.  The  disease  not  only  attacks 
infants,  but  older  children  and  (though  less  frequently) 
adults  may  contract  it.  The  incidence  fluctuates  from 
year  to  year  and  from  place  to  place. 

Control.  —  Until  more  is  known  about  the  modes  of 
transmission,  cases  should  be  reported  and  isolated  in  the 
usual  manner,  with  disinfection  of  all  discharges  from  the 
body.  Insects  should  be  excluded  by  screens.  For  pro- 
phylaxis on  the  part  of  the  nurse,  physician  and  other  per- 
sons possibly  exposed  to  infection,  gargles,  sprays,  and  nose 
washes  of  i  per  cent  peroxide  of  hydrogen  are  recommended. 
(Rosenau.)  The  proper  duration  of  isolation  is  entirely 
unknown,  but  it  seems  wise  to  keep  children  at  home  from 
school  for  three  weeks  after  recovery  from  acute  symptoms; 
a  longer  time  would  probably  be  safer. 

As  an  auxiliary  measure  the  suppression  of  flies  (which 
include  the  stable  fly)  should  be  adopted  (see  Chapter  VI). 
House  and  street  dust  should  be  kept  down.  "During 
epidemics    children    should    be    kept    away    from    public 


COMMUNICABLE  DISEASE  245 

gatherings,  prohibited  from  using  pubHc  drinking  cups  and 
special  attention  given  to  the  diet  to  prevent  gastrointes- 
tinal disorders,  for  many  a  case  of  infantile  paralysis  starts 
with  a  digestive  upset."     (Rosenau.) 

There  is  great  need  of  further  knowledge  from  epidemi- 
ological study  of  cases  and  carriers  as  well  as  from  labo- 
ratory experimentation. 

CHICKENPOX 

Chickenpox  is  a  mild  disease  of  the  class  of  commu- 
nicable exanthemata  (or  eruptive  diseases).  It  should  be 
made  reportable  for  the  reason  that  it  may  be  confused 
with  smallpox.  In  the  presence  of  smallpox  suspicious 
cases  of  chickenpox  should  be  examined  in  order  to  make 
sure  they  are  not  smallpox.  The  differential  diagnosis  of 
the  two  diseases  is  mentioned  under  the  head  of  Smallpox. 

Children  having  chickenpox  should  be  reported  by  the 
health  department  to  the  school  authorities  in  order  that 
they  may  be  excluded.  Chickenpox  is  subject  to  home  iso- 
lation and  disinfection  at  the  will  of  family  and  physician. 
No  restrictive  measures  are  taken  by  health  authorities. 
The  mortality  is  slight,  complications  and  sequelae  rare. 

SEPTIC   SORE  THROAT 

A  milk-borne  disease  of  peculiar  interest  is  "septic  sore 
throat,"  a  severe  type  of  tonsillitis  which  has  occurred  in  a 
number  of  epidemics.  The  infection  is  presumed  to  be  a 
streptococcus  infection  from  human  cases,  though  strepto- 
cocci found  in  udder  inflammations  of  cows  have  also  been 
suspected.  The  most  conspicuous  epidemic  in  this  coun- 
try occurred  in  Boston  and  vicinity  in  191 1  (1400  cases). 
It  has  been  instructively  studied  by  Winslow,^  who  con- 
cludes: "The  lesson  to  be  drawn  from  the  outbreak  is  that 
even  a  most  carefully  supervised  milk  supply  is  open  to  the 

1  Jour.  Inf.  Dis.,  1912,  vol.  X,  no.  i,  pp.  73-112. 


246  A  MANUAL  FOR  HEALTH  OFFICERS 

danger  of  grave  infection  from  carrier  or  unrecognized 
cases  of  disease.  The  only  real  safeguard  against  such 
catastrophes  Hes  in  pasteurization,  carried  out  by  the  hold- 
ing system  and  preferably  in  the  final  package." 

Cases  of  septic  sore  throat  should  be  reportable  with  the 
name  of  the  milk  dealer.  Cases  should  be  excluded  from 
schools.      On  epidemics  see  page  288. 

TETANUS 

While  tetanus  is  today  not  ordinarily  transmitted  directly 
from  person  to  person,  it  is  a  dangerous  infectious  dis- 
ease, the  germs  of  which  are  widely  spread  in  the  environ- 
ment, and  hence  requires  notice  here.  Tetanus  is  an  acute 
and  (in  the  absence  of  antitoxin  treatment)  fatal  intoxi- 
cation of  the  nervous  system,  characterized  by  muscular 
spasms  (hence  the  popular  name  "lock-jaw"),  and  caused 
by  the  toxin  of  the  tetanus  bacillus. 

Tetanus  is  almost  always  a  wound  infection.  It  may, 
however,  gain  admittance  through  contaminated  bacterial 
vaccines,  antitoxin  sera,  vaccine  virus  and  other  products 
used  in  human  therapy,  though  since  the  institution  of 
more  careful  supervision  of  biological  products  this  rarely 
occurs.  Tetanus  has  in  a  few  cases  occurred  as  a  com- 
plication of  vaccination,  due  either  to  impure  virus  or 
wound  infection.  Gelatin  may  contain  tetanus  spores, 
and  when  used  for  subcutaneous  injection  as  a  haemostatic 
should  be  thoroughly  sterilized.  "Idiopathic  tetanus"  is 
the  term  used  when  the  site  of  the  germ  in  the  system  is 
undetected. 

The  bacillus  is  harbored  and  thought  to  grow  in  the 
intestinal  tracts  of  herbivorous  animals,  notably  the  horse; 
it  passes  off  in  the  manure,  forms  highly  resistant  spores  ^ 
and  through  conveyance  by  manure,  dust,  flies,  etc.,  be- 
comes very  widely  disseminated.  It  is  one  of  the  very  few 
infectious  diseases,  the  germs  of  which  exist  in  considerable 

»  See  p.  571- 


COMMUNICMilJC    DISKASK  247 

numbers  for  long  periods  of  time  in  tlic  soil,  dirt ,  dust,  etc., 
in  the  environment. 

1336  deaths  from  tetanus  occurred  in  the  Registration 
Area  in  1911.  Nearly  all  (jf  these  might  have  been  pre- 
vented had  wounds  been  properly  treated  or  tetanus  anti- 
toxin administered  in  time. 

Control.  —  The  prophylaxis  of  tetanus  rests  with  the 
physician.  The  first  precaution  is  the  proper  surgical 
treatment  of  wounds.  Punctured,  lacerated  and  contused 
wounds  are  more  susceptible  than  clean-cut  or  superficial 
wounds,  for  the  reason  that  the  bacillus  —  being  a  strict 
anaerobe  —  develops  only  in  the  absence  of  air  and  oxy- 
gen. Even  small  wounds,  by  splinters,  etc.,  may  develop 
tetanus  if  conditions  are  favorable  to  it.  Rough  wounds, 
such  as  those  caused  by  rusty  nails  and  by  gunpowder 
explosion,  are  particularly  dangerous.  The  objects  of  the 
surgical  treatment  are  to  cleanse,  or  even  disinfect  the 
wound,  and  to  avoid  anaerobic  conditions. 

The  second  precaution  is  the  prophylactic  use  of  tetanus 
antitoxin.  This  means  the  prompt  administration  of  a 
small  dose  —  at  least  1500  units  —  in  the  case  of  all  sus- 
picious wounds.  The  promptness  of  administration  is 
important  for  the  reason  that  once  symptoms  appear  the 
damage  is  largely  done.^  It  may  be  necessary  to  repeat 
the  dose  every  ten  days  or  two  weeks  in  order  to  keep  up 
the  immunity  in  case  the  wound  does  not  heal  well. 

The  duties  of  the  local  health  authorities  embrace  educating 
the  public  as  to  the  importance  of  obtaining  proper  surgical 
treatment  of  wounds,  and  supplying  and  encouraging  the 
use  of  antitoxin   (free  in   the  cases  of  indigent  persons). 

^  However,  the  administration  of  heroic  doses  late  is  sometimes 
successful.  "  As  soon  as  symptoms  appear  20,000  units  or  more  of 
tetanus  antitoxin  should  be  introduced  directly  into  the  circulation  by 
intravenous  injection;  some  antitoxin  may  also  be  injected  into  the 
nerves  leading  from  the  wound.  In  tetanus,  as  in  diphtheria,  time  is 
the  important  element.  A  few  units  introduced  early  are  worth  more 
than  thousands  late."     (Rosenau.) 


248  A   MANUAL  FOR   Hl^ALTII  OFFICERS 

Dangerous    Fourth-of-July    celebrations    should    be    dis- 
couraged.^ 

GLANDERS 

"Glanders,  or  farcy,  is  a  widespread  communicable 
disease  of  horses,  mules,  asses  and  other  animals,  and  is 
readily  communicated  to  man.  In  both  man  and  horses 
it  is  remarkable  for  its  fatality.  This  disease  is  charac- 
terized by  the  formation  of  inflammatory  nodules  either 
in  the  mucous  membrane  of  the  nose  (glanders)  or  in  the 
skin  (farcy)."     (Rosenau.) 

The  cause  of  glanders  is  the  Bacillus  mallei,  which  is 
usually  communicated  from  animal  to  animal  or  to  man 
(occasionally  from  man  to  man)  through  contact  infection. 
The  germs  are  shed  off  in  the  discharges  from  mouth  and 
nose,  and  enter  the  system  through  the  skin  or  mucous 
membrane. 

The  diagnosis  of  glanders  may  be  made  according  to  any 
one  of  live  methods,  the  most  satisfactory  of  which  is  the 
complement  fixation  (serum)  test.^  Mallcin  in  skilled 
hands  is  useful,  but  not  accurate  in  all  cases. 

The  germ  is  destroyed  by  the  usual  disinfection  methods, 
but  thorough  cleanliness  is  necessary  in  order  to  do  away 
with  the  filth  in  which  it  may  be  embedded. 

Control.  —  The  radical  measure  is  the  elimination  of 
glanders  in  horses.  Frequently  the  health  authorities  are 
charged  with  this  responsibility.  All  cases  of  glanders  in 
beast  or  man  should  be  promptly  reported  by  veterinary, 
physician   or   owner   of   animal.     If   necessary,    provision 

^  Under  the  leadership  of  the  American  Medical  Association  a 
highly  successful  campaign  has  been  carried  on  in  recent  years  against 
the  dangerous  accidents  incident  to  Fourth-of-July  celebrations.  Not 
only  has  there  been  brought  about  greater  precautionary  treatment 
of  wounds  and  prophylactic  use  of  antitoxin,  but  the  occurrence  of 
accidents  has  been  diminished  through  saner  methods  of  celebration. 
This  is  true  preventive  work  of  an  important  kind. 

2  Described  in  Bull.  136,  Bureau  of  Animal  Industry,  Dept.  of  Agri- 
culture, Washington,  D.  C. 


COMMUNICABLE   DISEASE  249 

should  be  made  for  serum  diagnosis.  Any  animal  affected 
with  the  disease  should  be  at  once  destroyed  and  the  carcass 
properly  disposed  of,  and  the  stable  should  be  vacated 
and  disinfected  (see  Appendix  A).  Suspected  animals, 
other  animals  in  the  stable  and  animals  which  have  been 
otherwise  exposed  should  be  segregated  in  a  separate  stable 
and  subjected  to  the  blood  serum  fixation  test;  those 
reacting  should  be  destroyed,  carcasses  properly  disposed 
of  and  stable  disinfected.  Surveillance  of  the  remaining 
animals,  with  blood  serum  tests  every  three  weeks,  should 
be  continued  until  the  infection  has  been  eliminated. 
Needless  to  say,  each  animal  under  surveillance  should  be 
isolated,  with  separate  troughs,  harness,  brushes  and  other 
utensils. 

In  disinfection  pay  special  attention  to  troughs,  water 
buckets,  bits,  halters  and  other  articles  readily  infected 
by  secretions  of  nose  and  mouth.  Those  handling  infected 
animals,  carcasses  or  articles  should  wear  gloves  which 
may  be  destroyed  or  disinfected  and  should  avoid  possible 
infection  by  nose  and  mouth. 

Vigorous  measures  are  necessary  for  the  control  of 
glanders,  which  frequently  means  great  pains  and  expense 
and  the  destruction  of  valuable  animals,  but  the  authorities 
should  not  hesitate  to  proceed  firmly  and  thoroughly. 

Glanders  among  horses  frequently  occurs  in  epidemics, 
during  which  it  is  spread  by  watering  troughs,  hitching 
posts  and  other  media  of  contact.  It  is  therefore  some- 
times necessary  to  close  all  such  troughs  and  to  place  warn- 
ings on  public  hitching  places.  The  existence  of  many 
mild  and  missed  —  perhaps  even  carrier  —  cases  among 
horses  makes  the  disease  difficult  to  control  except  by  strict 
measures. 

The  prevention  of  infection  from  a  human  case  of  glan- 
ders would  consist  in  disinfection  of  sputum  and  dis- 
charges from  the  nose,  and  measures  to  avoid  infection  of 
other  persons  by  contact. 


250  A  MANUAL   FOR  HEALTH  OFFICERS 

ANTHRAX 

Anthrax  is  another  of  the  diseases  which  may  be  trans- 
mitted from  animals  to  man.  It  is  primarily  a  disease 
of  horses,  cattle,  sheep  and  other  cloven-hoofed  animals, 
caused  by  the  Bacillus  anthmcis.  It  is  known  also  as 
splenic  fever,  wool-sorter's  disease  (anthrax  of  the  lungs), 
and  malignant  pustule  (anthrax  of  the  skin).  The  follow- 
ing modes  of  infection  may  be  mentioned:  by  the  skin, 
i.e.,  through  abrasions,  etc.;  by  the  lungs,  apparently 
through  inhalation  of  spores;  by  the  digestive  tract, 
through  eating  raw  or  incompletely  cooked  infected  meat; 
ordinary  flies  may  convey  the  germ  to  the  skin,  and  the 
disease  may  be  inoculated  through  the  bite  of  the  stable 
fly.  Anthrax  spores  have  been  found  in  pastures  where 
infected  animals  have  been  confined.  Persons  working 
about  the  carcasses  of  slaughtered  animals,  butchers  and 
persons  who  handle  hides  and  hair  of  infected  animals 
may  be  infected.  Veterinary  surgeons  may  contract 
the  disease  through  accidental  infection  in  autopsies. 
It  is  a  rapidly  fatal  but  fortunately  not  a  common 
disease. 

Control.  —  The  control  of  anthrax  is  a  question  of  the 
disease  in  animals.  In  infected  animals  the  germs  exist  in 
great  numbers  in  the  internal  organs,  expecially  the  spleen, 
and  in  the  blood,  which  turns  dark.  On  being  exposed  to 
the  air  the  bacilli  form  highly  resistant  spores;^  hence 
great  care  should  be  taken  to  avoid  opening  any  infected 
carcass  or  letting  the  blood.  Infected  carcasses  should 
either  be  burned  or  be  buried  to  a  depth  of  at  least  three 
feet  so  as  to  avoid  soil  infection.  In  large  slaughter- 
houses they  may  be  "tanked,"  i.e.,  subjected  to  prolonged 
exposure  to  steam  under  pressure. 

Hides,  horse-hair  and  other  raw  material  used  in  trades 

»  See  p.  571. 


COMMON rCAI'.IJ';    DfSEASK  25T 

and  liable  to  conlain  the  infection  of  the  resistant  anthrax 
spore  should  be  disinfected  before  use.^ 

PELLAGRA 

Pellagra  is  a  disease  of  obscure  causation  which  has 
become  prominent  of  recent  years.  In  191 1,  659  deaths 
were  ascribed  to  it  in  the  Registration  Area,  and  Lavender, 
of  the  U.  S.  Public  Health  Service,  estimates  that  there 
are  now  between  25,000  and  50,000  pellagrins  in  the 
United  States. 

There  are  two  principal  theories  as  to  the  causation: 
(i)  that  it  is  due  to  the  ingestion  of  spoiled  corn  or  maize; 
(2)  that  it  is  a  communicable  disease  transmitted  by  the  bite 
of  an  insect.2  It  is  on  the  first  of  these  theories  that  pre- 
ventive measures  looking  to  corn  supplies  have  been  adopted 
in  Italy,  which  is  one  of  the  centers  of  the  disease.  Ob- 
servers working  on  the  insect  theory  have  brought  forward 
evidence  tending  to  convict  the  Simulium  fly,  the  Stomoxys 
fly  (or  ordinary  stable  fly) ,  the  house  fly  or  some  species  of 
mosquito,  which,  however,  is  not  conclusive.  It  has  also 
been  observed  that  pellagra  is  more  prevalent  where  pov- 
erty, uncleanliness,  overcrowding  and  other  poor  social 
conditions  are  present.  As  the  result  of  recent  investiga- 
tion, the   Thompson-McFadden  Pellagra    Commission    of 

^  The  following  method  is  recommended  by  Pouder  {Lancet,  London, 
vol.  CLXXXI,  no.  4601,  pp.  1247-1314),  as  quoted  by  Rosenau: 

"  The  dry  hides  are  placed  for  24  hours  in  a  "  soak  "  which  is  made 
to  contain  i  to  2  per  cent  of  formic  acid  and  0.02  per  cent  of  bichlorid 
of  mercury,  and  then  salting  them  with  sodium  chlorid.  The  action 
of  the  "  soak  "  is  to  swell  up  the  fibers  of  the  hide  by  causing  them  to 
absorb  water,  the  result  being  that  the  hide  returns  to  a  condition 
closely  resembling  that  in  which  it  was  taken  from  the  animal's  carcass. 
This  permits  the  bichlorid  of  mercury  to  permeate  and  exert  its  germ- 
icidal action." 

'  Experts  of  the  U.  S.  Public  Health  Service  have  recently  been 
working  on  the  theory  that  pellagra  is  one  of  the  so-called  starvation 
diseases,  like  scur\-y  and  beri-beri.  Intestinal  organisms  have  also  been 
claimed  to  have  been  found. 


252  A  MANUAL  FOR  HEALTH  OFFICERS 

the  New  York  Post-Graduate  Medical  School  and  Hospital 
has  recorded  itself  as  discarding  the  spoiled  maize  theory; 
the  evidence  favoring  the  theory  that  the  disease  is  conveyed 
by  a  blood-sucking  insect,  very  possibly  the  stable  fly. 

Solution  of  the  problem  raised  by  pellagra  must  be  sought 
in  the  outcome  of  such  researches,  as  recorded  in  current 
medical  and  public  health  literature  and  in  the  proceedings 
of  the  National  Association  for  Study  of  Pellagra.* 

LEPROSY 

{Lepra) 

Leprosy  is  occasionally  met  with  in  the  United  States, 
though  conditions  are  unfavorable  to  its  spread  in  this 
country.  It  is  caused  by  the  Bacillus  leprcB  and  is  com- 
municable, though  to  a  less  extent  than  popularly  supposed. 
The  mode  of  infection  is  probably  always  by  direct  contact, 
but  "prolonged  and  intimate  association  with  .a  leper 
ordinarily  seems  necessary  to  contract  the  infection." 
(Rosenau.) 

Leprosy  should  be  reported.  Prophylaxis  consists  in 
cleanliness,  care  of  infected  discharges  and  the  usual 
measures  to  prevent  ordinary  contact  infection.  Partic- 
ular attention  should  be  paid  to  the  nasal  secretions,  which 
at  one  stage  or  another  become  infective  in  the  great  ma- 
jority of  cases.  Some  degree  of  isolation  may  be  neces- 
sary for  some  cases,  though  (according  to  Rosenau)  there 
should  be,  in  this  country,  little  objection  to  giving  liberty 
to  a  careful  leper  of  cleanly  habits.  Segregation  of  lepers 
in  institutions  is  the  commonly  accepted  administrative 
measure.  The  disease  is  not  invariably  fatal,  but  may  be 
treated  like  tuberculosis,  which  in  certain  respects  it  re- 
sembles. 

'  Cf.  Rosenau,  "  Preventive  Medicine  and  Hygiene,"  1913,  and 
Roberts,  "  Pellagra:  History,  Distribution,  Diagnosis,  Prognosis, 
Etiology,  Treatment,"  1912. 


COMMUNICABLE  DISEASE  253 

Dr.  II.  W.  HilP  has  pointed  out  the  non-identity  of 
modern  leprosy  and  Biblical  leprosy,  with  the  statement: 

Modern  leprosy  should  never  be  called  by  that  name,  but  always 
designated  as  lepra;  and  every  effort  should  be  made  to  point  out  that 
it  is  produced  by  a  well-known  germ,  belonging  to  the  tuberculosis 
group;  and  is  in  clinical  effect  a  second  cousin,  so  to  speak,  of  tubercu- 
losis, but  much  more  infectious  —  a  disease  to  be  supervised  and  pre- 
vented from  spreading,  of  course,  but  calling  for  no  panic-stricken  flights 
from  its  neighborhood  and  no  especial  hardships  or  cruelty  to  its  unfor- 
tunate victims. 

MENTAL    DISEASES 

We  may  here  mention  the  various  insanities  and  psy- 
choses which  are  chiefly  due  to  syphilis,  alcoholism  and 
heredity.  While  this  class  of  disease  is  not  at  present 
subject  to  direct  attack  by  health  authorities,  it  may  never- 
theless be  said  that  preventive  methods  may  reduce  one 
set  of  the  underlying  causes  —  syphilis,  typhoid  fever 
and  other  infectious  diseases;  while  sanitation  tends  to 
improve  some  of  the  conditions  which  favor  another  — 
alcoholism. 

OTHER   DISEASES 

Some  other  diseases  which  are  spread  by  milk  or  meat 
are  mentioned  under  the  head  of  Food  Supplies.  Tropical 
diseases  and  other  diseases  of  interest  chiefly  to  the  para- 
sitologist or  quarantine  ofificer  are  omitted.  In  case  of  the 
appearance  of  a  rare  communicable  disease,  local  author- 
ities should  notify  the  state  and  Federal  authorities  and 
be  guided  by  their  advice. 

Industrial  poisonings  are  mentioned  under  the  head  of 
Factory  Hygiene. 

The  control  of  the  drug  habit  through  registration  of 
cases  and  restrictions  on  the  sale  of  habit-forming  drugs 
has  recently  been  taken  up  by  some  local  health  author- 

1  Am.  Jour.  Pub.  Health,  1914,  vol.  IV,  no.  7,  p.  605. 


254  A  MANUAL  FOR  HEALTH  OFFICERS 

ities,  and  was  extensively  discussed  at  the  19 14  meeting  of 
the  American  Pubhc  Health  Association.^ 

Progressive  health  authorities  may  also  interest  them- 
selves in  the  movement  for  suppression  of  patent  medicines 
and  quack  frauds  which  has  been  ably  begun  by  the 
American  Medical  Association  and  the  press. 

THE   SCHOOLS   IN   RELATION   TO    COMMUNI- 
CABLE  DISEASE 

School  Exclusions.  —  Cases  of  diphtheria,  scarlet  fever, 
measles,  whooping  cough,  chickenpox,  mumps,  etc.,  should 
be  promptly  reported  by  the  health  office  to  the  school 
authorities  (see  page  105)  in  order  that  the  latter  may  see 
that  the  rules  as  to  exclusions  of  children  in  infected  families 
and  houses  are  strictly  obeyed.  The  rules  should  be  made 
by  the  health  authorities  (unless  there  is  a  system  of  medical 
inspection  in  the  schools,  in  which  case  the  medical  inspec- 
tor should  be  consulted)  and  should  be  enforced  by  health 
and  educational  authorities  in  cooperation. 

The  rules  for  exclusion  adopted  vary  with  different 
authorities,  but  under  each  of  the  principal  diseases,  in 
previous  pages,  we  have  given  some  indication  of  the  best 
practice.  For  others  the  practice  may  be  inferred  from  the 
nature  of  the  disease.  There  are  a  number  of  minor  con- 
tagious afTections  of  children  which  the  health  department 
leaves  entirely  to  medical  inspectors  of  schools. 

The  same  rules  should  apply  to  all  public,  parochial  and 
private  schools,  Sunday  schools  and  other  occasions  of 
commingling  of  children.  Such  rules  apply  with  special 
force  to  the  primary  schools,  where  children  mingle  inti- 

^  Terry,  "  Drug  Addictions,  A  Public  Health  Problem,"  Am.  Jour. 
Pub.  Health,  1914,  vol.  IV,  no.  i,  p.  28.  Cf.  Wilbert  and  Motter, 
"  Digest  of  Laws  and  Regulations  in  Force  in  the  United  States  relating 
to  the  Possession,  L^se,  Sale,  and  Manufacture  of  Poisons  and  Habit- 
forming  Drugs,"  Pub.  Health  Bull.  no.  56,  U.  S.  Pub.  Health  Service, 
1912. 


COMMUNICABLE   DISEASE  255 

mately;  in  the  high  school  there  is  comparatively  little 
association  and  the  rules  need  not  there  apply  except  under 
unusual  conditions. 

As  to  the  exclusion  of  teachers  living  in  infected  families, 
each  case  should  be  judged  on  its  merits.  There  is  less 
contact  between  teacher  and  pupil  than  between  pupils, 
and  the  restrictions  on  teachers  (except,  perhaps,  in  the 
kindergarten  grades,  where  chances  of  contact  are  more 
frequent)  need  not,  therefore,  be  so  strict.  If  the  condi- 
tions are  satisfactory,  they  may  be  permitted  to  continue 
at  their  work.  Otherwise,  the  case  may  be  sent  to  the 
hospital,  or  the  teacher  may  live  elsewhere  during  the  course 
of  the  disease. 

Closure  of  Schools.  —  The  question  of  closing  the  schools 
in  order  to  check  epidemic  disease  presents  itself  at  times 
to  the  health  authorities,  particularly  in  connection  with 
measles.  Similar  question  arises  in  regard  to  Sunday 
schools,  moving  picture  theatres,  children's  parties  and 
the  like.  It  is  a  question  not  to  be  lightly  decided,  for  the 
closure  of  schools  means  a  loss  to  the  community  warrant- 
able only  by  grave  reasons. 

The  problem  is  really  one  as  to  the  role  of  the  schools  in 
the  propagation  of  communicable  disease.  The  popular 
idea  that  the  schools  are  great  distributors  of  disease  is 
not  clearly  confirmed  by  careful  observation  and  study. 
The  chief  argument  for  it  is  the  increase  of  scarlet  fever, 
diphtheria,  measles,  etc.,  during  the  school  year,  but  this 
fact  is  by  no  means  conclusive,  for  these  diseases  all  affect 
the  respiratory  system  and  we  know  that  all  respiratory 
diseases  are  much  more  prevalent  in  the  winter  season. 
Thus  there  may  be  merely  a  coincidence  between  the 
school  term  and  the  winter  season.  There  is,  of  course, 
no  question  but  that  infection  does  take  place  through 
association  of  children  in  the  schools,  but  the  amount  of 
it,  as  compared  with  infection  through  association  outside, 
has  probably  been  exaggerated. 


256  A  MANUAL  FOR  HEALTH  OFFICERS 

The  fact  that  there  are  considerable  numbers  of  cases 
in  the  schools  does  not  necessarily  signify  that  they  origi- 
nated there.  If  there  is  a  school  focus  of  infection  it  will 
appear  in  one  class-room,  one  grade  or  one  school,  and  may 
be  dealt  with  separately  by  rigid  medical  inspection  (in 
diphtheria,  culturing)  and  exclusion  of  contacts.  Nor 
does  the  dying-out  of  an  epidemic  after  school  closure  neces- 
sarily mean  that  the  latter  was  the  cause  of  the  cessation, 
for  epidemics  frequently  die  out  of  themselves  for  lack  of 
further  susceptible  human  material  in  their  path.  Measles, 
for  example,  recurs  in  seemingly  inevitable  waves  every 
few  years,  sweeping  through  the  community  in  spite  of  the 
most  rigid  measures. 

It  is  in  any  case  bad  practice  to  close  schools  and  keep 
them  closed  for  weeks  without  any  apparent  benefit.  If 
there  is  any  benefit  in  school  closure  it  will  be  noticed 
immediately  after  the  lapse  of  the  incubation  period  of 
the  disease  (say  two  weeks  for  measles).  But  experience 
frequently  shows  that  there  are  other  factors  than  the  school 
at  work,  and  that  it  is  useless  to  keep  the  latter  closed  for 
long  periods. 

Let  us  consider  the  apparent  effects  of  closing  school,  and 
in  doing  so  observe  the  important  distinction  between 
urban  and  rural  conditions. 

I.  In  urban  districts  there  may  be  just  as  many  oppor- 
tunities for  contact  in  play  in  the  streets  and  houses  as  in 
school  —  perhaps  more.  Furthermore,  the  school  is  the 
only  place  where  medical  inspection  can  be  performed,  and 
if  the  school  is  closed  this  important  means  of  detecting 
carriers  and  mild  cases  is  cut  off. 

Children  associate  most  closely  in  their  play;  hence,  ap- 
parently, it  is  the  association  in  play  occasioned  by  the 
school,  rather  than  the  comparatively  small  amount  of  con- 
tact in  the  classroom,  which  favors  spread  of  infection.  If 
this  opportunity  for  play  association  be  compared  with  the 
opportunities   for  such   association   in   homes,  streets  and 


COMMUNICAI'.I.K    DISKASK  257 

elsewhere  (for  which  there  is  more  time  when  schools  are 
closed),  it  will  be  seen  to  constitute  but  a  part  of  a  wifler 
problem  which  is  solved  only  in  part  —  often,  perhaps,  in 
comparatively  small  part  —  by  school  closure.  (It  is  as- 
sumed that  the  opportunities  for  contact  infection  in  the 
school  plant —  through  common  drinking  cups,  roller  towels, 
etc.  —  have  been  so  far  as  possible  removed.) 

Many  of  the  best  authorities  now  believe  that  the  reduc- 
tion of  opportunities  of  contact  infection  in  the  school 
and  careful  medical  inspection  of  school-children  to  detect 
incipient  cases  —  rather  than  school  closure  —  are  the  most 
effective  ways  of  controlling  communicable  disease  even 
when  epidemic.  In  spite  of  popular  clamor,  observant  city 
health  officers  are  becoming  less  and  less  inclined,  on  the 
whole,  to  order  closure  of  schools. 

A  recent  paper^  sums  up  the  above  view  in  an  admirable 
manner.  From  it  the  following  quotations  are  taken. 
(In  quoting  some  of  the  phrases  have  been  combined  for 
the  sake  of  concentration.) 

The  arguments  in  favor  of  closing  the  schools  seem  to  be  based 
chiefly  upon  tradition  and  public  demand  and  not  upon  careful  study 
of  the  manner  in  which  infection  is  transmitted  in  and  out  of  schools.  .  .  . 

There  is  undoubtedly  a  rise  in  the  curve  of  incidence  of  the  commoner 
communicable  diseases  of  childhood  shortly  after  the  opening  of  the 
schools  in  the  autumn,  and  the  natural  inference  is  that  the  opening  of 
the  schools  is  the  cause  of  this  rise,  but  a  more  careful  study  of  the 
curve  shows  that  this  is  not  the  fact. 

[As  further  data  tending  to  diminish  the  importance  attributed  to 
the  schools,  figures  are  given  showing  that  there  are  more  cases  of 
scarlet  fever  during  the  years  before  children  enter  school  than  after.] 

In  two  instances  lately  [in  Newton,  Mass.]  where  the  outbreaks 
were  due  to  missed  cases  which  were  in  the  schools  for  some  time  before 

*  Curtis,  "  Shall  We  Close  the  Schools  During  Epidemics?"  Am. 
Jour.  Pub.  Health,  1914,  vol.  IV,  no.  2,  p.  135;  see  also  Chapin,  Rpt. 
of  Supt.  of  Health,  Providence,  R.  I.,  for  1912,  pp.  34-41;  Roach, 
"  The  Role  of  the  School  in  the  Spread  of  Scarlet  Fever,"  Am.  Jour. 
Pub.  Health,  1912,  vol.  II,  no.  6,  p.  450;  Note  regarding  English  study. 
Am.  Jour.  Pub.  Health,  191 2,  vol.  II,  no.  4,  p.  313;  Editorial,  Am. 
Jour.  Pub.  Health,  1912,  vol.  II,  no.  3,  p.  168. 


258  A  MANUAL   FOR   HEALTH  OFFICERS 

discovery,  the  first  cases  found  were  not  children  who  sat  near  the  in- 
fecting cases  nor  were  they  in  the  same  grade,  but  were  those  who  were 
their  playmates  and  companions  out  of  school.  More  recently,  in  an 
outbreak  of  diphtheria,  the  cases  were  similarly  infected.  ...  So  far 
as  they  go  these  instances  seem  to  show  that  infection  is  not  contracted 
in  the  school-room  as  frequently  as  is  usually  supposed. 

If  the  schools  are  closed  when  an  outbreak  occurs,  the  children  are 
turned  loose  from  superv'ision;  they  mingle  freely  with  one  another 
in  the  streets,  on  playgrounds  and  in  one  another's  houses.  They  are 
enjoying  themselves  thoroughly  and  are  unwilling  to  admit  that  they 
feel  ill,  lest  they  be  kept  at  home  and  prevented  from  having  a  good 
time.  For  this  reason  they  will  not  say  they  feel  ill  until  they  are 
possibly  well  advanced  and  they  may  be  active  sources  of  infection  for 
some  time  before  it  is  discovered  that  they  are  ill.  .  .  . 

If  the  schools  are  kept  open  and  the  children  continue  in  the  class- 
rooms as  usual,  they  are  under  strict  observation  and  examined  daily 
by  the  school  physicians,  suspicious  and  infected  cases  being  sent  home 
for  obsers-ation  or  treatment.  ...  It  seems,  therefore,  that  keeping 
the  schools  open  offers  the  best  chance  of  safety  for  the  scholars  both 
collectively  and  individually.  .  .  . 

The  school  physician  and  nurse  should  be  detailed  to  the  school 
w^here  the  outbreak  has  appeared  and  instructed  to  examine  every  child 
daily,'  excluding  such  as  appear  ill  or  suspicious.  This  can  be  done 
with  very  little  disturbance  of  the  school  work.  A  note  must  be  sent 
to  the  parent  stating  that  the  child  seems,  or  is,  ill  and  must  be  seen  by 
the  family  physician.  Suspicious  cases  must  be  ordered  to  remain  at 
home  until  further  notice,  and,  if  necessary,  must  be  visited  later  in 
order  to  settle  the  diagnosis.  Absentees  must  be  rounded  up  and  ex- 
amined in  order  to  find  out  why  they  have  been  kept  at  home.  If 
they  are  ill,  they  must  be  isolated,  and,  if  well,  urged  to  return  to  school. 
.  .  .  In  small  cities  the  school  physician  can  be  detailed  to  the  affected 
school  during  the  outbreak,  leaving  the  other  schools  in  his  district  to 
be  covered  by  one  of  his  colleagues. 

Even  if  extra  help  should  be  required  the  extra  expense  incurred  will 
be  more  than  offset  by  the  shortening  of  the  duration  of  the  outbreak 
and  the  lack  of  disturbance  to  the  schools. 

When  the  schools  are  closed  certain  expenses  such  as  salaries,  etc., 
continue  without  any  return  and  there  is  also  an  added  economic  loss 
from  the  lessening  of  the  time  for  instruction,  so  that  the  children  in 
the  affected  school  or  schools  are  behind  others  in  the  same  grade  in  the 
unaffected  schools. 

'  Such  examinations  should  be  made  hejore  the  children  enter  school 
each  day.  —  J.  S.  M. 


COMMUNICAI'.IJ',    DfSKASI-:  259 

[The  author  Lhen  discusses  ihc  necessity  of  persuarling  school  com- 
mittees (when  vested  with  this  j)ower)  to  keep  the  schools  ojjcn  and  of 
inducing  jjarents  to  keep  their  children  in  attendance.] 

2.  In  rural  districts,  on  the  other  liand,  adequate  medi- 
cal inspection  is  not  so  readily  obtained,  while  closing  the 
schools  does  operate  to  scatter  the  children  and  hence 
lessen  the  opportunities  of  infection.  The  case  here  is 
summed  up  in  an  editorial  in  the  American  Journal  oj 
Public  Health}  After  remarking  that  in  country  districts 
the  health  officer  is  commonly  a  part-time  physician  whose 
medical  practice  would  make  the  greatest  demands  at  just 
those  times  of  epidemic  when  he  would  be  most  needed 
as  medical  inspector,  the  writer  concludes: 

In  the 'country  the  children  come  to  school  from  widely  separated 
homes.  They  live  in  little  scattered  groups  whose  members  should  be 
quite  free  from  risk  from  the  outside.  The  school  brings  them  together. 
At  their  homes  they  do  not  gather  in  great  groups  on  the  streets.  The 
situation  is  radically  different  from  that  in  the  city,  and  it  would  seem 
that  the  greater  contact  is  in  the  school. 

The  rural  school  would  be  of  less  consequence  as  a  focus  were  a  system 
of  adequate  inspection  possible.  But  here  again  is  a  weak  spot  in  rural 
health  administration;  good  school  inspection  is  costly  and  in  the  coun- 
try it  is  difficult  to  maintain  of  standard  quality. 

Under  these  circumstances  and  until  the  efficiency  of  rural  health 
work  can  be  maintained  at  a  high  standard,  may  it  not  be  well  to  recog- 
nize a  differing  environment  and  allow  that  schools  and  churches,  even, 
.  .  .  may  be  closed  in  times  of  serious  outbreaks  as  a  measure  for  the 
protection  of  the  people? 

3.  The  matter  may  be  summed  up  in  saying  that  in 
sparsely  populated  country  districts,  where  the  children  do 
not  associate  to  any  general  extent  except  at  school,  clo- 
sure may  be  effective;  but  that  in  towns  and  cities  where 
there  is  certain  to  be  a  great  deal  of  association  in  any 
case,  it  is  of  doubtful  if  of  any  value.  In  the  latter  case, 
taking  into  account  the  educational  and  economic  losses 
involved,  it  would  appear,  on  the  above  argument,  inad- 

*  19 14,  vol.  IV,  no.  5,  p.  436. 


26o  A  MANUAL   FOR  HEALTH  OFFICERS 

visable  to  close  schools,  reliance  being  placed  instead  on 
careful  medical  inspection. 

MEDICAL  INSPECTION  OF  SCHOOL-CHILDREN 

Medical  inspection  systems  now  exist  in  many  public 
schools  and  should  be  universal.  Such  inspection  has 
two  objects:  (i)  the  general  physical  welfare  of  each  child, 
and  (2)  the  detection  and  exclusion  of  communicable 
disease.  The  former  object  consumes  the  greater  effort 
and  expense,  but  only  the  latter  will  concern  us  for  the 
present. 

Detection  and  Exclusion  of  Communicable  Disease.  — 
Medical  inspection  of  schools  plays  an  important  part  in 
that  surveillance  over  childhood  which  is  one  of  the  founda- 
tions of  the  control  of  communicable  disease.  The  factors 
in  such  surveillance  are:  the  parents,  the  family  physician, 
the  health  authorities,  the  teacher,  the  school  medical 
inspector  and  the  school  nurse.  How  important  is  the 
part  played  by  each  of  these?  The  parents  frequently  fail 
to  recognize  incipient  cases  of  communicable  disease  in 
their  children.  The  family  physician  has  no  opportunity 
to  detect  such  disease  unless  called  by  the  family;  fre- 
quently he  is  called  late  or  not  at  all.  The  health  author- 
ities in  their  turn  depend  upon  official  notification  from 
physicians.  In  the  school,  the  teacher  may,  or,  more 
frequently,  may  not,  be  able  and  apt  to  recognize  suspicious 
symptoms  in  children;  her  chief  concern  is  for  instruction, 
not  physical  inspection.  But  the  medical  inspector  is  a 
specialist,  one  of  whose  principal  objects  is  to  detect  in- 
cipient or  atypical  communicable  disease;  and  if  he  is 
assisted,  as  he  should  be,  by  the  school  nurse,  his  effective- 
ness is  greatly  enhanced.  Medical  inspection  is  therefore 
a  main  barrier  against  communicable  disease. 

The  ideal  plan  is  to  have  the  physician  visit  the  school 
in  the  morning  as  soon  as  possible  after  opening.  Sus- 
picious cases  have  meanwhile  been  singled  out  from  the 


COMMUNICATU.K    DTSKASK  261 

classes  by  the  school  nurse  by  means  of  .1  general  inspec- 
tion, and  kept  in  a  special  room  for  examination  by  the 
physician.  Such  inspections  should  be  performed  early, 
so  that  any  excludable  cases  may  be  detected  before  the 
pupils  mingle  together  in  classes  and  play.  Teachc-rs 
should  receive  simple  instructions  on  the  early  symptoms 
in  children.  The  school  nurse  "follows  up"  pupils  for 
whom  examination  by  family  physician  or  home  treatment 
has  been  indicated,  in  order  to  see  that  the  parents  give 
proper  attention.  Complete  medical  inspection  of  each 
pupil  is  made  once  a  year.  Such  an  ideal  plan  may  not 
be  possible  in  all  communities,  but  should  be  adopted  as 
far  as  possible.  For  further  details  see  the  references 
below. 

Medical  inspectors  should  be  required  personally  to  re- 
port all  cases  promptly  to  the  health  department,  using  a 
special  form  for  that  purpose. 

(For  further  details  and  discussion  of  medical  inspection  of  schools, 
with  references,  see  Chapter  II.) 

SCHOOL  HYGIENE  AND   SANITATION 

School  Sanitation.  —  The  most  popular  measure  for 
restricting  communicable  disease  in  schools  is  room  fumi- 
gation. This  process  is  supposed  to  wipe  out  all  infection 
and  gives  a  sense  of  security  to  parents  and  teachers,  which, 
however,  we  now  know  is  false.  It  is  safe  to  say  most  of 
the  room  fumigation  as  ordinarily  performed  in  school- 
buildings  today  is  inefifective  if  not  needless.  The  present 
day  science  of  epidemiology  shows  that  the  source  of  in- 
fection in  schools  is  not  the  atmosphere  of  an  "infected 
school-room"  but  the  mild  and  unrecognized  cases  of  com- 
municable disease  which  spread  the  disease  by  contact 
infection  among  the  children.  It  is  a  common  experience 
to  go  to  great  pains  and  expense  to  disinfect  school-rooms 
only  to  have  fresh  cases  appear  as  if  no  "precautions"  had 
been  taken. 


262  A  MANUAL   FOR   HEALTH  OFFICERS 

The  best  safeguards  are  cleanliness  and  a  simple  use  of 
disinfectants.  Things  frequently  handled  or  touched  — 
e.g.,  door-knobs,'  railings,  gymnastic  apparatus,  toilet  fix- 
tures and  the  like  —  should  be  cleansed  thoroughly  once  a 
week  and  should  be  gone  over  each  day  with  a  cloth  wet 
with  formalin  solution,  coal-tar  mixture,  or  other  reliable 
disinfectant.  Water-closets  should  be  kept  scrupulously 
clean  and  the  seats,  door-knobs,  chain-pulls,  etc.,  should  be 
disinfected  daily  in  the  manner  just  described.  If,  in  spite 
of  the  cleansing,  a  deodorant  is  needed  in  toilet  rooms 
they  may  be  whitewashed  or  one  of  the  deodorants  men- 
tioned on  page  591  may  be  used. 

Dust  should  be  wiped  off  furniture  with  damp  cloths 
(not  feather  dusters,  which  merely  move  dust  without 
removing  it).  As  to  the  floors,  floor-oil  is  an  effective  dust- 
eliminant.  Black-board  chalk  should  be  removed  after 
school  hours  with  wet  cloths,  not  erasers. 

Common  drinking  cups  and  common  towels  should  be 
absolutely  tabooed;  sanitary  fountains  and  paper  towels 
may  be  substituted.  Instead  of  the  common  soap  cake, 
liquid  soap  apparatus  may  be  used. 

Why  fumigate  desks  (which  are  used  by  the  chil- 
dren individually,  not  in  common)  and  other  furniture 
(which  is  scarcely  touched  by  the  children  at  all)  when 
the  amount  of  infection  spread  by  these  is  apparently  so 
small  as  to  be  negligible,  and  at  the  same  time  neglect  — 
as  is  frequently  the  case  —  the  real  means  of  common 
contact? 

Instruction  in  Hygiene.  —  School  instruction  should  not 
only  include  a  course  in  general  hygiene  but  should  dwell 
especially  on  the  means  of  avoiding  contact  infection. 
This  should  begin  with  the  youngest  children  —  even  in 
kindergarten,  where  the  teachers  may  inculcate  habits  of 
personal  cleanliness  and  avoidance  of  spreading  one's 
secretions  or  taking  up  those  of  others.  As  soon  as  children 
can  read  sufficiently  well  they  may  be  given  cards  contain- 


COMMUNICAHIJ';    hISKASE  263 

ing  simple  precepts  of  the  kind  illustrated  in  the  following 
example:  ^ 

REMEMBER   THESE   THINGS 

Do  not  spit  if  you  can  help  il.  Never  spit  on  a  slate,  floor  or  side- 
walk. 

Do  not  put  the  fingers  into  the  mouth. 

Do  not  pick  the  nose  or  wipe  the  nose  on  the  hanrl  or  sleeve. 

Do  not  wet  the  fingers  in  the  mouth  wlien  turning  the  leaves  of 
books. 

Do  not  put  pencils  into  the  mouth  or  wet  them  with  the  lips. 

Do  not  put  money  into  the  mouth. 

Do  not  put  pins  into  the  mouth. 

Do  not  put  anything  into  the  mouth  except  food  and  drink. 

Do  not  swap  apple  cores,  candy,  chewing  gum,  half-eaten  food, 
whistles  or  bean  blowers,  or  anything  that  is  put  into  the  mouth. 

Never  cough  or  sneeze  in  a  person's  face.  Turn  your  face  to  one 
side. 

Keep  your  face  and  hands  clean;  wash  the  hands  with  soap  and  water 
before  each  meal. 

LIBRARIES 

Epidemiology  teaches  that  the  dangers  of  transmission 
of  disease  by  books  are  comparatively  small.  Neverthe- 
less some  precautions  are  advisable.  First,  cases  of  com- 
municable disease  (and  terminations  of  cases)  should  be 
reported  by  the  health  authorities  to  the  circulating  librar- 
ies, public  and  private.  Then  books  returned  from  quar- 
antined families  should  be  subjected  to  disinfection  (see 
Appendix  A).  If  they  are  of  little  value,  and  especially 
if  they  have  been  handled  by  the  patient,  they  should  be 
burned,  preferably  without  being  taken  away  from  the 
house. 

1  Composed  by  C.  V.  Chapin,  and  used  in  the  public  schools  of 
Providence,  R.  I.  Placards  bearing  the  same  text  are  posted  in  con- 
spicuous places  in  the  school-rooms.  In  the  public  schools  of  New 
York  City  jingles  on  such  texts  have  been  printed  on  cards  and  circu- 
lated. Such  verses  doubtless  fix  themselves  more  firmly  in  the  minds 
of  young  children  than  abstract  prose  texts. 


264  A  MANUAL  FOR  HEALTH  OFFICERS 

With  tuberculosis  there  is  some  slight  possibility  of  trans- 
mission by  books.  Tuberculosis  patients  need  not,  how- 
ever, be  forbidden  to  use  library  books  if  such  books  are 
effectively  disinfected  by  the  health  or  library  authorities. 
Clean  and  careful  consumptives  can  probably  use  books 
without  special  danger  to  other  persons  even  without  dis- 
infection. 

GENERAL   REGULATIONS   AGAINST   CONTACT   INFECTION 

Under  the  head  of  contact  infection  were  suggested  some  of  the  gen- 
eral modes  of  infection  among  the  public,  involving  hand-to-hand  and 
hand-to-mouth  transmission.  We  may  here  mention  some  of  those 
which  should  be  dealt  with  by  sanitary  regulation. 

Common  Drinking  Cups,  Roller  Towels,  etc'  —  The  common  drink- 
ing Clip  has  long  since  been  convicted  as  a  medium  of  infection,  and 
should  be  abolished  in  all  public  places,  as  has  been  done  by  various 
state  and  local  laws.  In  its  stead  may  be  substituted  the  automatic 
drinking  fountain  or  individual  cups.  Paraffined  paper  cups  which 
may  be  discarded  after  use  are  to  be  recommended  when  not  too  ex- 
pensive. Bubbling  fountains  should  be  so  designed  that  it  is  impossible 
to  apply  the  m-outh  before  the  water  begins  to  flow.  Ordinances 
should  enumerate  specifically  the  places  —  schools,  hotels,  railroad  sta- 
tions, parks,  theaters,  libraries,  churches,  municipal  buildings,  public 
institutions,  factories  and  the  like  —  where  the  regulation  is  to  apply. 
This  is  most  properly  a  subject  for  state  legislation,  for  the  state  author- 
ities alone  can  properly  enforce  it  in  railroad  trains  and  steamboats. 
Local  authorities  should,  however,  enforce  the  state  law,  or,  if  necessary, 
pass  their  own  ordinances.  Common  drinking  cups  and  common  towels 
have  been  abolished  by  Federal  authority  in  interstate  railroad  trains, 
and  vessels  and  stations. 

At  soda  fountains,  thorough  washing  of  glasses  should  be  insisted 
upon  or  paper  cups  substituted.  The  washing  of  glasses  in  saloons 
is  also  a  matter  for  inspection. 

The  objections  to  the  common  drinking  cup  apply  with  equal  force 
to  the  common  or  roller  towel,  which  in  addition  plays  a  role  in  the  spread 
of  diseases  of  the  eye.  Towels  used  in  schools,  public  lavatories,  hotels, 
restaurants,  department  stores,  etc.,  and  the  common  bar  towel,  fall 

'  Cf.  Kerr  and  Moll,  "  Common  Drinking  Cups  and  Roller  Towels: 
An  Analysis  of  the  Laws  and  Regulations  Relating  Thereto  in  Force 
in  the  United  States,"  Public  Health  Bulletin  no.  57,  U.  S.  Public 
Health  Service   1 9 1 2 . 


COMMUNICABLE  DISEASE  265 

under  this  ban.  Individual  towels  which  arc  used  only  once  before 
beinfi;  washed,  or  (he  paper  towels  which  are  now  su]j])lied  at  a  low  cost 
by  manufacturers,  should  be  substituted.  In  this  connection  it  would 
be  well  to  abolish  common  .soap  cakes  and  toilet  articles,  particularly 
in  schools,  where  the  possibilities  of  contact  infection  are  most  to  be 
guarded  against.  Liquid  soap  apparatus  for  lavatories  may  readily 
be  substituted. 

Among  other  possible  mediums  of  contact  infection  to  which  atten- 
tion may  be  drawn  —  though  of  secondary  importance  —  are  finger- 
bowls,  the  forks  used  in  free  lunches,  cigar-cutters  (the  cigar  being 
moistened  with  saliva  before  cutting),  lung  testers,  and  suction  shuttels 
in  textile  factories.  Milk  tickets  which  are  used  more  than  once 
should  be  forbidden.  The  possibility  of  contamination  of  ice-water 
tanks  through  unclean  methods  of  handling  the  ice  should  not  be  over- 
looked, nor  the  contamination  of  bread  and  other  foods  through  im- 
proper handling.  Various  other  modes  of  public  or  semi-public  contact 
infection  will  suggest  themselves. 

Barber  Shops.  —  Skin  diseases  and  other  affections  may  be  acquired 
in  barber  shops.  No  person  affected  with  venereal  disease  should  be 
permitted  to  act  as  a  barber.  The  following  rules  (Ordinance  of  Mont- 
clair,  N.  J.,  Board  of  Health)  indicate  the  kind  of  regulation  that  may 
be  applied  to  barber  shops. 

SEC.  I.     Every  barber  shop  within  the  Town  of shall  be 

open  to  this  Board  for  inspection  at  any  time,  and  the  following 

rules  shall  be  observed  therein: 

(a)  All  barber  shops,  together  with  all  furniture,  shall  be  kept 
in  a  clean  and  sanitary  condition. 

(b)  Mugs,  shaving  brushes,  razors,  scissors,  clipping  machines, 
pincers,  needles  and  other  instruments  shall  be  sterilized,  either 
by  immersion  in  boiling  water  or  in  alcohol  of  at  least  sixty  per 
cent  strength,  after  each  separate  use.  Combs  and  brushes  shall 
be  thoroughly  cleaned  with  soap  and  water  after  each  separate 
use. 

(c)  Clean  towels  shall  be  used  for  each  person. 

{d)  Alum,  or  other  material  used  to  stop  the  flow  of  blood,  shall 
be  applied  only  on  a  clean  towel  or  other  clean  cloth. 

The  use  of  powder  puffs  and  sponges  is  prohibited,  except  that 
a  sponge  owned  by  a  customer  may  be  used  on  him. 

(e)  Every  barber  shall  thoroughly  cleanse  his  hands  immediately 
before  serving  each  customer. 

(/)  Every  barber  shop  shall  be  well  ventilated  and  provided 
with  running  hot  and  cold  water. 

(g)  No  barber  shop  shall  be  used  as  a  sleeping  room. 


266  A  MANUAL   FOR   HEALTH  OFFICERS 

(//)  A  copy  of  this  article  shall  be  kept  posted  in  plain  view  in 
every  barber  shop. 

SEC.   2.     Any   person   violating  any   of  the  provisions  of  this 
article  shall,  upon  conviction  thereof,  forfeit  and  pay  a  penalty  of 
ten  dollars  for  each  offense. 
[Provision  recently  added:] 

No  person  shall  hereafter  operate  a  barber  shop  until  he  has 
filed  with  the  Board  of  Health  a  certificate  signed  by  a  regularly 
licensed  ph)-sician,  who  is  approved  by  the  Board,  that  all  persons 
who  wait  upon  customers  in  his  establishment  have  been  exam- 
ined by  the  said  physician  within  30  days  and  show  no  evidence  of 
any  communicable  disease.     Such  examination  shall  include  any 
tests  that  the  Board  may,  by  resolution,  prescribe.     Like  certifi- 
cates must  thereafter  be  filed  every  three  months  on  the  first  days 
of  January,  April,  July  and  October  of  each  year  for  examinations 
that  have  been  made  of  all  such   persons  during  the  previous 
month,  and  additional  certificates  must  be  filed  for  all   new  em- 
ployees as  soon  as  they  begin  their  duties.     All  certificates  must 
be  on  forms  furnished  by  the  Board  and  must  give  the  name  of 
every  person  examined.      [Penalty,  $25.] 
Public  baths  and  swimming  pools  have  been  suspected  of  transmitting 
eye  affections,  typhoid  fever  and  other  diseases.     They  may  be  dis- 
infected and  at  the  same  time  rendered  sweeter,  with  a  very  consider- 
able saving  of  water  which  would  otherwise  have  to  be  changed,  by  a 
dose  daily  to  weekly  of  i  to  il  pounds  of  bleaching  powder  (hypochlo- 
rite of  lime)  per  100,000  gallons.^ 

Some  health  departments  attempt  to  regulate  "  rummage  sales  " 
of  old  clothes,  the  stocks  of  rag-dealers  and  the  like,  requiring  a  so-called 
disinfection  of  the  articles.  Efficient  disinfection  is  impossible  without 
great  trouble  and  expense,  and  the  modern  disproof  of  the  importance 
of  fomites  infection  indicates  that  the  supervision  of  such  matters  is, 
in  any  large  view,  a  waste  of  time  and  labor.  Better  to  put  more  at- 
tention on  the  real  and  obvious  modes  of  contact  infection. 

EPIDEMIOLOGY 

(The  following  section  is  introduced  not  only  for  its  particular  sug- 
gestions in  dealing  with  epidemics,  but  also  for  the  general  indications 
which  it  gives  regarding  the  various  modes  of  disease  transmission.) 

The  practical  study  of  the  characteristics  of  epidemics,  or,  more 
generally  speaking,  of  the  modes  of  transmission  of  communicable 
diseases,  is  known  as  epidemiology.  This  science,  in  spite  of  its  some- 
what imposing  name,  consists  simply  in  the  application  of  common 
*  Hooker,  "  Chloride  of  Lime  in  Sanitation,"  1913,  p.  29. 


COMMUNICABLE  DISKASE  267 

sense,  joined  with  a  basic  knowlcd^jc  of  the  modes  of  transmission,  to 
the  pi'of)lenis  arising  in  practical  jjublic  health  work.  It  is  a  species  of 
scientific  detective  work.  We  can  here  give  merely  a  sketch  of  the 
methods  to  be  followed. 

Terms.  —  Any  outbreak  of  communicable  disease  may  be  termed 
an  epidemic.  'Ihe  following  allied  terms  are  also  applied  to  commu- 
nicable disease: 

Endemic.  —  Constantly  present  in  a  community  to  a  greater  or  less 
extent. 

Pandemic.  —  Epidemic  over  wide  areas. 

Prosodemic.  —  Spreading  continually  from  person  to  person  in  a 
chainlikc  fashion  (Sedgwick  and  Winslow). 

Epizootic. — Attacking  many  animals  at  once;  —  said  of  diseases 
analogous  to  epidemic  diseases  among  men. 

These  terms  may  be  used  substantively  as  well  as  adjectively.  Thus 
we  speak  of  an  "  epidemic  "  or  of  an  "  epidemic  disease." 

The  Prevention  of  Epidemics.  —  The  importance  of  scientific  safe- 
guards against  the  occurrence  of  epidemics  cannot  be  overestimated; 
anyone  who  has  surveyed  the  history  of  the  numerous  epidemics  which 
have  occurred  even  within  recent  years  is  struck  with  their  disastrous 
effects.  The  cases  in  individual  milk-borne  epidemics  not  infrequently 
run  up  into  the  hundreds  (or  even,  as  in  the  instance  of  typhoid  fever 
in  Boston,  1908,  into  four  figures) ;  hundreds  or  thousands  of  preventable 
cases  occur  every  year  in  communities  having  polluted  water-supplies, 
while  the  constant  succession  of  contact  cases  occurring  everywhere 
often  outweighs  even  the  other  two  classes. 

Care  and  watchfulness  on  the  part  of  the  health  authorities  will  pre- 
vent many  an  epidemic,  or  at  least  check  it  in  the  beginning.  Health 
officers  should  be  familiar  with  the  "  normal,"^  or  usual,  rates  of  occur- 
rence and  distributions  of  the  various  communicable  diseases.  Ob- 
servation shows  that  in  any  given  community  the  cases  of,  say,  scarlet 
fever  or  diphtheria  occur  each  year  with  considerable  regularity  as  to 
numbers  in  the  various  sections  of  the  town  and  are  pretty  evenlj'  dis- 
tributed among  the  schools  and  on  the  routes  of  the  various  milk  dealers 
(taking  into  account  the  number  of  customers  served  by  each).  There 
are  also  important  "  normal  "  seasonal  distributions.  Thus  scarlet 
fever,  diphtheria  and  other  diseases  in  which  the  infection  is  spread 
through  the  secretions  of  the  nose,  throat  and  respiratory-  system,  and 
which  are  contracted  through  those  channels  usually  show  a  regular 
increase  beginning  in  September  or  October,  rising  to  a  maximum  in 
mid-winter,  falling  off  during  the  spring,  and  remaining  at  a  minimum 
during  the  summer  months.  Measles,  however,  is  somewhat  an  excep- 
'  For  comment  on  this  term,  see  p.  501. 


268  A  MANUAL  FOR   HEALTH   01  TICKKS 

tion  in  that  the  winter  maximum  does  not  usually  occur  until  late 
winter  or  early  spring.  Typhoid  fever,  in  communities  where  water- 
borne  typhoid  is  eliminated  and  only  the  "  residual  "  '  remains,  has  a 
low  incidence  during  the  winter  months,  but  gradually  rises  during  the 
summer,  its  incidence  closely  following  the  curve  for  temperature. 
The  curve  is  smooth  and  regular,  and  only  in  communities  having  in- 
fected milk  and  water  supplies  do  there  occur  marked  and  irregular 
increases  at  all  seasons  of  the  year.- 

If  the  health  officer  is  familiar  with  such  basic  considerations  and 
keeps  a  careful  watch  over  the  occurrence  of  cases  in  his  district,  he 
will  at  once  note  any  considerable  irregularity  which  may  be  the  first 
signal  of  an  incipient  outbreak.  For  this  purpose  the  records  and  charts 
recommended  in  the  early  part  of  the  present  chapter  are  adequate, 
though  in  the  larger  cities  they  may  be  supplemented  by  special  means, 
such  as  a  separate  chart  for  milk  dealers,  etc'  On  the  "  spot  map  " 
Joci  of  contact  infection  may  readily  be  detected.  Since  it  is  the  first 
cases  in  an  epidemic  which  are  of  the  greatest  importance  in  control, 
the  necessity  of  constant  watchfulness  to  detect  such  cases  is  e%'ident. 

INVESTIGATION  OF  EPIDEMICS 

If  an  epidemic  is  recognized  to  be  present,  a  systematic  investiga- 
tion must  be  made,  with  the  following  objects  in  view: '' 

1.  To  ascertain  whether  or  not  the  disease  is  actually  present,  and  if 
so,  whether  as  a  general  epidemic  or  as  a  local  outbreak. 

2.  To  discover  the  cause. 

3.  To  remove  the  cause. 

4.  To  prevent  further  spread  of  the  disease. 

1  See  the  section  on  Typhoid  Fever. 

^  See  Rosenau,  "  Preventive  Medicine  and  Hygiene,  1913,  p.  79. 

'  Such  records  should  of  course  be  considered  with  reference  to  the 
number  of  customers  served  by  each  dealer.  The  natural  chances  of 
occurrence  of  cases  on  the  routes  of  dealers  supplying  various  numbers 
of  customers  have  been  worked  out  in  mathematical  form  by  Carpenter 
("  The  Distribution  of  Cases  Among  the  Several  Producers  in  Epidemics 
of  Non-milk-borne  Infectious  Disease,"  Am.  Jour.  Pub.  Health,  1912, 
vol.  II,  no.  4,  p.  296),  indicating  the  number  of  cases  which  might  be 
allowed  to  each  of  such  dealers  without  suspicion  of  infection  of  their 
supplies. 

""  The  following  remarks  are  based  largely  upon  Whipple's  "  Typhoid 
Fever,"  1908,  Chapter  IX,  on  "  The  Investigation  and  Control  of 
Typhoid  Fever  Epidemics."  Very  much  the  same  principles  apply  to 
other  diseases. 


COMMUNICAIUJ';    DISKASK  2O9 

Collection  and  Study  of  Data 

These  steps  involve  first  of  all  the  collection  of  data,  for  which  purpose 
a  regular  form  of  history  card  should  he  used.  The  data  necessary 
may  be  obtained  in  a  personal  interview  in  each  family  where  a  case 
has  been  reported,  supplemented,  if  necessary,  by  information  from 
physicians'  histories.  Needless  to  say,  it  is  assumed  thai  all  cases  are 
strictly  reported.  From  the  beginning  the  data  are  studied  with  the 
prime  object  of  discovering  a  common  cause.  The  following  remarks 
sketch  the  procedure  in  investigating  a  typhoid  fever  epidemic,  a  pro- 
cedure which  illustrates  in  a  general  way  the  methods  followed  in  in- 
vestigating other  diseases. 

As  fast  as  the  data  are  obtained  they  should  be  tabulated  and 
studied  from  various  points  of  view. 

Were  the  cases  generally  distributed  over  the  city  or  were  they 
confined  to  one  locality?  A  convenient  method  of  ascertaining 
this  is  to  take  a  street  map  and  locate  the  cases  with  black-headed 
pins  stuck  in  at  the  place  of  residence.  This  map,  with  its  pins, 
can  afterwards  be  photographed  for  record.  If  the  cases  are 
localized,  does  the  locality  suggest  anything  as  to  a  common 
cause?  Is  it  coincident  with  some  particular  water  supply,  as  it 
was  in  New  Haven,  or  with  some  milk  dealer's  territory,  as  in 
Somerville?  Is  it  located  in  a  section  where  there  are  no  sewers, 
as  in  Winnipeg?  Is  it  around  some  public  well,  as  in  Newport? 
Or  are  the  cases  merely  concentrated  in  one  place  because  the  popu- 
lation is  densest  there?  Does  the  geographical  distribution  of  the 
cases  change  as  the  epidemic  progresses?  Where  were  the  early 
cases  with  respect  to  the  others? 

What  was  the  probable  date  of  infection?  Was  there  a  sudden, 
sharp  attack,  or  was  the  onset  gradual?  If  the  latter  was  the 
case,  what  were  the  limiting  dates  of  infection?  The  date  of  in- 
fection has  to  be  estimated  by  counting  back  from  the  time  when 
the  patient  was  taken  sick.  All  things  considered,  the  safest  date 
to  count  from  is  that  of  taking  bed.  Often  this  cannot  be  learned, 
especially  if  the  investigation  is  made  sometime  afterwards.  But 
the  date  of  going  to  bed  is  seldom  far  from  the  time  of  the  physician's 
first  call,  and  this  can  usually  be  obtained  from  the  doctor's  mem- 
oranda. If  the  epidemic  is  believed  to  be  due  to  milk,  or  oysters, 
or  some  other  cause  involving  an  intense  form  of  infection,  the  prob- 
able date  when  the  patient  received  the  bacilli  into  his  system  may 
be  obtained  by  counting  back  7  to  10  days;  but  if  a  water  infection 
is  suspected,  a  period  of  10  to  15  days  will  probably  give  a  better 
estimate.  It  must  be  remembered,  however,  that  occasionally 
the  period  of  incubation  may  be  considerably  longer  than  this. 


270  A  MANUAL   FOR   IIKALTH   OFFICERS 

Sometimes  it  is  necessary-  to  count  back  from  the  appearance  of 
some  particular  symptom,  and  in  that  case  the  attending  physi- 
cian's advice  should  be  obtained  as  to  whether  this  occurred  in  the 
second  or  third  or  fourth  week  of  the  disease.  Sometimes  one  has 
to  figure  back  from  the  date  of  death.  That  also  is  something 
about  which  the  attending  physician  should  be  consulted. 

Were  there  any  outbreaks  of  diarrhcra  preceding  the  typhoid 
epidemic?     When  and  among  whom  did  they  occur? 

Were  most  of  the  cases  among  young  people  and  children? 
If  so,  this  suggests  milk  as  a  cause.  Did  they  all  or  most  of  them 
use  the  same  water-supply,  or  take  milk  from  the  same  dealer,  or 
food  from  the  same  source? 

Had  the  patients  been  together  anywhere,  at  business  or  in 
school,  or  at  some  banquet? 

In  short,  was  there  any  common  cause  where  eating  or  drinking 
or  association  might  give  opportunity  for  infection?  ' 

Special  Investigation 

In  seeking  the  origin,  any  possible  cause  upon  which  the  data  clearly 
cast  .suspicion  should  be  subjected  to  special  investigation  in  order  to 
obtain  the  confirmatory  evidence  upon  which  a  positive  conclusion  can 
be  based.  Thus,  for  typhoid  fever,  the  public  water  supply,  if  thus 
suspected,  may  be  specially  inspected  and  analyzed  for  possible  pollution, 
likewise  private  or  local  water  supplies.  If  a  milk  supply  is  suspected 
it  may  be  gone  over  from  farm  to  consumer,  with  search  for  past  or 
present  cases  of  suspicious  sickness,  especially  by  the  use  of  Widal 
tests  applied  to  all  persons  in  any  way  concerned  in  the  handling  of 
the  milk  or  milk  utensils.  The  milk  dealer  will  usually  cooperate 
if  there  is  danger  of  his  business  being  stopped,  though  skill  and 
tact  are  necessary  to  obtain  reliable  statements  as  to  illnesses.  Again, 
a  suspected  supply  of  oysters  or  other  shellfish  may  be  investigated. 
Of  course  such  investigations  are  not  made  in  a  general  manner  at  the 
beginning  of  the  inquiry,  for  such  would  be  a  needless  waste  of  energy, 
but  only  when  study  of  the  data  points  to  some  particular  source  of 
infection.  Sometimes  it  so  happens  that  the  source  of  the  epidemic  is 
located  —  as  in  some  particular  milk  supply  —  but  the  original  case 
itself  cannot  be  identified  on  account  of  insufficiency  of  evidence.  In 
all  of  this  the  services  of  an  expert  must  be  relied  upon,  and  the  local 
health  officer  may  frequently  require  the  assistance  of  the  state  author- 
ities. In  fact  it  is  the  part  of  wisdom  to  call  in  such  assistance  at  the 
very  beginning  of  the  epidemic  rather  than  rely  upon  the  limited  famil- 
iarity with  epidemiology  which  the  local  health  officer  usually  possesses. 
1  Whipple,  op.  cit.,  pp.  219-221. 


COMMUNICABLE  DISEASE  271 

Removing  the  Cause  —  Checking  Lhe  ILjndemic 

The  cause  having  been  discovered,  it  remains  to  remove  it.  If  it 
be  a  well  or  other  private  water  supply,  it  may  be  at  once  permanently 
closed.  If  the  public  supply,  then  it  may  be  scientifically  disinfected 
(see  page  412),  this  being  the  best  temporary  expedient.  Otherwise,  it 
may  be  necessary  to  publish  notices  to  "  boil  the  water,"  or  to  furnish 
a  pure  supply  by  house-to-house  delivery.  Then  steps  should  be  taken 
to  provide  a  permanent  remedy  through  purification  or  substitution 
of  the  public  supply.  A  water-borne  epidemic  may  bring  out  the 
difference  between  contamination,  or  jjollution,  and  infection.  A  water 
supply  may  be  polluted  even  for  years  without  apparent  evil  results, 
but  just  as  soon  as  infection  gains  entrance  with  the  pollution  the  weak 
spot  becomes  disastrously  apparent. 

If  it  is  a  milk  supply  that  is  infected,  it  should  be  stopped  until  and 
unless  it  be  rendered  safe.  Safety  can  be  obtained  only  by  removal 
or  complete  isolation  of  the  case  and  sterilization,  under  the  supervision 
of  the  health  authorities,  of  all  utensils  used  in  connection  with  the 
milk.  No  person  who  has  had  the  disease  or  whose  blood  .shows  a  posi- 
tive Widal  should  be  permitted  to  take  part  in  the  business  until  re- 
peated examinations  of  stools  and  urine  are  negative  (see  section  on 
typhoid  fever).  As  a  temporary  expedient  to  permit  the  continued 
sale  of  the  milk  pasteurization,  provided  it  is  efficient,  may  be  allowed. 
In  this  the  possibility  of  the  infection  of  the  milk  through  contaminated 
bottles  or  utensils  must  not  be  forgotten,  hence  equal  care  must  be  taken 
in  the  sterilization  of  these  and  in  the  methods  of  operation.  It  may 
happen  that  bottles  and  utensils  are  infected  in  handling  or  through 
washing  in  an  impure  water  supply,  and  bottles  maj'  be  infected  (as 
has  happened  in  a  number  of  epidemics)  at  the  houses  of  customers. 
The  permanent  remedy  is  the  sterilization  of  all  milk  bottles  and  utensils 
and  the  pasteurization  of  all  milk. 

If  the  epidemic  is  extensive  it  may  be  necessary  to  arrange  for  special 
services  for  the  sick  in  the  shape  of  extra  physicians  and  nurses  and  per- 
haps to  establish  a  temporary  hospital,  for  the  hospital  plaj'S  an  im- 
portant part  in  preventing  the  contact  infection  which  is  favored  by 
poor  home  conditions.  Cheap  and  effective  disinfectants  should  be 
distributed  free  or  at  cost  and  their  use  described  and  insisted  upon. 
Facilities  for  making  blood  tests  should  be  provided.  And  all  cases 
should  be  promptly  and  thoroughly-  isolated  as  described  under  the 
section  on  typhoid  fever. 

Through  it  all,  a  "  safe  and  sane  policy  "  should  be  consistently 
'  pursued.     A  community  afflicted  with  an  .  .  .  epidemic  is  some- 

times almost  panic-stricken.     Correspondents  may  fill  the  public 
press  with  their  theories,  and  many  foolish  things  may  be  said  and 


272  A  MANUAL  FOR  HEALTH  OFFICERS 

done.     What  is  needed  is  a  strong  central  authority  that  for  a  time 
can  exercise  almost  autocratic  power,  and  a  government  and  a 
public  opinion  that  will  uphold  such  authority,  and  provide  all 
necessary   resources.     Fortunate,   indeed,   is  the  city   that   has  a 
health  officer  or  health  department  equipped  for  such  an  emergency 
and  a  government  that  will  rise  to  the  occasion.' 
It  may  be  added  that  care  should  be  taken  not  to  leap  to  premature 
conclusions  as  to  the  source  of  an  epidemic.     The  usual  procedure  is  a 
course  of  elimination.     Thus  if  the  cases  are  clearly  localized  and  the 
general  water  supply  is  evidently  not  responsible,  then  this  fact  may  be 
publicly  announced,  while  the  investigation  goes  forward  in  other  direc- 
tions.    Again,  if  the  cases  are  distributed  pro  rata  among  various  milk 
dealers  and  it  is  certain  that  there  is  no  common  milk  supply  involved, 
then  this  fact  may  be  given  out.     Such  elimination  plays  an  important 
part,  not  only  in  the  investigation  but  also  in  calming  the  public  mind. 

Prevention  of  Future  Outbreaks 

When  the  source  of  the  epidemic  has  been  discovered  and  the  situation 
has  been  brought  under  control,  the  investigation  may  be  rounded  out 
by  the  collection  of  data  which  will  have  a  practical  bearing  in  prevent- 
ing future  outbreaks,  through  improving  and  safeguarding  water  sup- 
plies, obtaining  increased  funds  and  better  methods  for  sanitary  control, 
and  the  like.  Sometimes  useful  data  may  be  collected  to  show  the 
financial  damage  produced  by  the  epidemic.  Thus  the  Pittsburgh  Sur-  ■ 
vey  (1908)-  as  the  result  of  its  researches  estimated  the  average  cost 
in  medical  attendance,  loss  of  work,  etc.,  for  each  case  as  $125,  and 
$2200  for  the  fatal  cases.  The  computable  value  of  prevention  is  illus- 
trated specifically  by  the  following  statement  bearing  on  the  purification 
of  public  water  supplies: 

The  filtration  of  a  polluted  public  water  supply  increases  to  a 

very  great  extent  the  vital  assets  of  a  community,  and  the  increase 

in  most  cases  is  many  times  greater  than  the  cost  of  constructing 

and  operating  the  works.  ...     [In  Albany,  N.  Y.,  for  example] 

the  increased  worth  of   the  water  .  .  .  amounts  to  $475,000  per 

year,  of  which  at  least  $350,000  may  be  considered  as  a  real  increase 

in  the  vital  assets  of  the  city.^ 

A  similar  argument  might  well  be  made  out  for  the  pasteurization  of 

milk  supplies  or  any  other  sanitary  measure.     All  such  expenditures 

constitute  truly,  as  Whipple  remarks,  a  kind  of  community  life  insurance. 

1  Whipple,  op.  cit.,  p.  226. 

2  See  Whipple,  op.  cit.,  Appendix  XIV,  also  p.  275.  ' 
5  Whipple,  op.  cit.,  p.  280  f.     Cf.  "The  Value  of  Pure  Water,"  by 

the  same  author. 


COMMUNICABLE   DISEASE  273 

TYPES  AND   CHARACTERISTICS  OF  INDUCTION 

The  hcakh  official  should  have  a  knowlcflgc  of  the  various  types  of 
infection.  The  following  is  a  sketch  of  some  of  the  more  important 
points,  arranged  according  to  the  modes  of  transmission: 

Contact.  —  Practically  any  of  the  communicable  diseases,  with  the 
exception  of  those  which  have  an  intermediary  host,  may  be  spread  by 
contact.'  The  characteristic  of  contact  infection  is  its  straggling 
appearance.  Most  of  the  endemic  diseases  show  this  clearly,  e.g., 
scarlet  fever,  diphtheria,  and  typhoid  fever.  To  the  constant  chain 
of  cases  of  these  diseases  which  are  practically  always  to  a  greater  or 
less  extent  present  in  the  community  Sedgwick  and  Winslow  have  ap- 
plied the  term  "  prosodemic  "  ("  proceeding  through  the  community  "). 
The  principal  means  of  this  infection  are  "  food,  fingers  and  flies," 
all  of  which  in  this  connection  rank  as  varieties  of  contact  infection. 
When  a  disease  is  spread  from  person  to  person  rather  than  through  a 
common  medium  affecting  large  numbers  of  people  at  once  its  progress 
is  ordinarily  more  gradual  but  more  difficult  to  control.  Fairly  dis- 
tinct contact  epidemics  may,  however,  occur  (see  under  Examples, 
below). 

Water.  —  The  chief  diseases  transmitted  by  water  are  typhoid  fever, 
gastrointestinal  diseases  and  Asiatic  cholera.  Epidemics  are  usually 
gradual  in  onset  and  in  decline.  If  there  is  simply  a  single  infection  of 
a  water  supply  which  quickly  ceases,  the  cases  will  gradually  rise  to  a 
maximum  and  then  slowly  decline.  But  if  the  supply  is  subject  to 
continual  infection  the  number  of  cases  will  tend  to  stay  up,  with  fluc- 
tuations according  to  the  amounts  of  infecting  material  present  from 
time  to  time.  A  small,  continued  amount  of  infection  may,  however, 
produce  the  same  sort  of  effect  as  contact  infection,  the  cases  appearing 
in  a  straggling  succession.  Water-borne  typhoid  fever  epidemics  are 
frequently  preceded  by  a  premonitory  outbreak  of  cases  of  gastro- 
intestinal disease  (the  incubation  of  the  latter  being  shorter);  of  this, 
unfortunately,  the  public  health  authorities  usually  have  little  or  no 
information,  though  it  has  been  aptly  suggested  that  cases  of  such 
sickness  should  be  made  reportable. 

Milk.  —  The  chief  diseases  transmitted  through  milk  are  typhoid 
fever,  scarlet  fever,  diphtheria,  septic  sore  throat  and  tuberculosis  (the 
last  is  taken  up  elsewhere  and  need  not  be  considered  here).  Milk 
epidemics  are  usually,  though  not  always,  characterized  by  suddenness 
of  onset.  This  is  explained  by  the  fact  that  the  dose  of  infection  may 
be  relatively  greater  than  in  water  supplies  but  especially  that,  milk 
being  an  excellent  culture  medium,  the  germs  may  multiply  greatly  in 

^  For  definition  and  discussion  see  p.  113. 


274  A  MANUAL   FOR   HEALTH  OFFICERS 

it.  The  relatively  high  prevalence  among  the  milk-drinking  portion 
of  the  population  —  viz.,  children  —  though  not  invariably  well 
marked,  is  also  characteristic  of  milk-borne  epidemics. 

Insects.  —  Infection  by  flies  and  other  insects  which  carry  infecting 
material  in  a  mechanical  manner  does  not  produce  marked  or  wide- 
spread epidemics  except  under  extraordinary  circumstances  (page  190  f.). 
The  relative  amount  of  such  infection  is  uncertain.  Cases  would  ap- 
pear according  to  the  prevalence  of  the  insects  and  the  opportunities 
for  infection;  thus  a  part  of  the  increase  in  typhoid  fever  during  the 
warmer  months  is  doubtless  due  to  infection  by  flies.  A  similar  prin- 
ciple applies  to  malaria  and  yellow  fever,  in  which  the  insect  (the  mos- 
quito) acts  as  intermediate  host  of  the  parasite.  These  diseases  occur 
according  to  the  prevalence  of  anopheles  and  a'cdes  (or  stegomyia)  mos- 
quitoes respectively,  and  according  to  the  opportunities  for  them  to 
become  infected  from  malaria  and  yellow  fever  patients  and  carriers. 

Primary  and  Secondary  Cases.  —  Distinction  should  be  made  between 
"  primary  cases  "  (those  due  directly  to  the  original  source  of  the 
epidemic)  and  "  secondary  cases  "  (those  contracted  from  the  primary 
cases  in  the  course  of  the  epidemic  or  shortly  after  it).  Secondary 
cases  are  sometimes  called  "  contact  cases,"  contact  being  the  usual 
mode  of  secondary  infection.  In  epidemics  due  primarily  to  water, 
milk,  etc.,  secondary  cases  should  be  guarded  against,  and  in  report- 
ing epidemics  should  be  included  under  a  separate  head. 

Epidemic  Curve.  —  As  implied  abo\e,  the  character  of  the  epidemic 
curve  when  the  cases  are  arranged  and  plotted  in  order  of  time  varies. 
Thus  there  is  the  explosive  type  (frequent  in  milk-borne  epidemics) 
and  the  wave-like  type,  in  which  the  incidence  of  cases  rises  gradually 
to  a  maximum  and  gradually  declines  (frequent  in  water-borne  infec- 
tion), as  well  as  the  straggling  appearance  of  cases  which  is  character- 
istic of  contact  infection.  The  types  are  thus  roughly  associated  with 
certain  modes  of  infection;  the  associations  are,  however,  not  at  all 
invariable. 

Carriers,  Missed  Cases,  Incipient  Cases.  —  These  important  classes 
of  cases  have  been  dwelt  upon  in  previous  pages.  They  have,  within  a 
few  years,  been  shown  greatly  to  aggravate  problems  of  control  and  to' 
add  an  entire  new  chapter  to  epidemiology,  revolutionizing  our  views  in 
important  respects.  A  long  list  might  be  compiled  of  epidemics  of  ty- 
phoid fever  and  diphtheria  due  to  carriers,  a  list  which  would  be  longer 
and  no  doubt  include  other  diseases  if  our  knowledge  of  causes  and  modes 
of  transmission  were  more  extensive.  The  study  of  every  epidemic 
should  include  a  careful  consideration  of  the  possibilities  of  the  activity 
of  this  class  of  cases.  Even  when  an  epidemic  is  not  due  to  a  carrier  or 
missed  case  the  probability  —  often  the  certainty  —  of  the  presence 


COMMUNICABLE  DISEASE  275 

of  such  cases  after  the  epidemic  is  under  way  slioiild  Ije  taken  into  ac- 
count. Unfortunately,  except  (chiefly)  for  tyjjlioid  fever  and  (lijjh- 
theria,  we  have  no  means  of  laboratory  diagnosis  for  such  cases. 

EXAMPLES  OF   EPIDEMICS 

No  attempt  can  here  be  made  to  sum  up  the  large  literature  dealing 
with  the  details  of  the  various  recorded  eitidcmics  of  different  kinds. 
The  following  examples,  while  more  or  less  typical,  merely  illustrate 
some  of  the  general  principles.  It  must  not  be  supposed  that  all  epi- 
demics follow  just  the  same  course.  The  details  of  each  require  in- 
dividual study,  for  all  the  text-book  points  are  frequently  not  present 
and  the  investigator  must  be  on  the  alert  for  the  atypical  and  unex- 
pected.^ We  are  not  dealing  here  with  hard  and  fast  effects,  but  with 
the  varied  phenomena  arising  from  the  interaction  of  many  different 
factors. 

Contact  Infection  (Typhoid  Fever) 

The  following  extract  is  from  the  report  of  Prof.  William  T.  Sedg- 
wick on  an  epidemic  of  typhoid  fever  at  Bondsville,  Massachusetts, 
1892,  which  was  one  of  the  first  to  direct  attention  to  the  importance 
of  contact  (at  that  time  called  "  secondary  ")  infection.^  This  account, 
though  written  over  twenty  years  ago,  illustrates  clearly  what  may 
readily  occur  today  in  any  community  where  ordinary  unsanitary 
privies  and  unclean  habits  of  living  exist.  After  remarking  upon  the 
well-water  and  tap-water  theories  which  the  investigator  found  popu- 
larly current  on  his  arrival,  he  goes  on  to  say: 

Consideration  of  Water  Supplies 

It  very  soon  appeared  that  the  cases  were  by  no  means  syn- 
chronous, but  showed  a  peculiar  and  interesting  succession.  At 
the  same  time  other  serious  objections  to  any  theory  of  water  in- 
fection began  to  appear.  In  the  first  place,  the  tap- water  theory 
was  untenable,  because  (i)  although  this  water  was  supplied  only 

1  For  example,  in  an  epidemic  of  milk-borne  typhoid  fever  investi- 
gated by  the  writer  in  Essex  County,  N.  J.,  spread  by  the  medium  of 
infected  milk  bottles,  it  was  noteworthy  that  the  typical  explosive 
incidence  did  not  occur,  for  the  cases  straggled  along  in  much  the  same 
manner  as  contact  cases;  neither  was  there  the  typical  incidence  among 
children,  for  out  of  24  cases  there  was  only  one  case  under  15  years 
of  age.  Moreover  a  number  of  the  cases  were  mild  and  clinically  atyp- 
ical. (Proceedings  4th  Ann.  Conf.  State  and  Local  Bds.  of  Health  of 
N.  J.,  1913,  p.  38.)     Such  atypicalness  is  not  at  all  infrequent. 

*  24th  Ann.  Rpt.  State  Board  of  Health  of  Mass.,  1892. 


276  A   MANU.\L  FOR   HEALTH  OFFICERS 

to  the  small  district  in  which  the  fever  appeared,  and  to  the  bleach- 
er>'  (as  may  be  seen  by  following  upon  the  map  the  broken  line 
coming  from  left  on  Front  Street),  and  was  therefore  curiously 
connected  with  the  infected  houses,  it  was  plain  that  but  little  if 
any  of  it  had  been  used  for  drinking,  on  account  of  the  prejudice 
against  it  referred  to  above;  and  (2)  because  many  of  the  tene- 
ments supplied  with  it,  as  well  as  the  very  populous  boarding- 
house,  had  been  entirely  exempt  from  the  fever.  So,  also,  was  it 
with  the  well-water  theory;  for,  while  at  first  this  looked  ex- 
tremely plausible,  it  was  difficult  to  see,  first,  how,  if  the  well  had 
been  really  infected,  more  cases  had  not  developed,  for  it  was  used 
by  everybody;  and,  second,  if  it  were  really  infected,  why  the 
cases  were  so  strangely  successive  and  not  simultaneous.  Be- 
sides all  this,  opposed  to  both  theories,  was  the  fact  that  there 
was  absolutely  no  evidence  of  any  specific  contamination  of  either 
tap  water  or  well  water  in  either  the  near  or  the  remote  past. 
When,  therefore,  the  bacteriological  and  chemical  examinations 
revealed  the  fact  that  both  waters  were,  considering  the  circum- 
stances, remarkably  pure,  both  theories  of  water  infection  neces- 
sarily fell  to  the  ground. 

Consideration  of  Milk  Supplies 

I  next  made  a  careful  study  of  the  milk  supply,  which  showed 
that  the  infected  families  had  several  different  milkmen.  Here, 
also,  the  remarkable  succession  of  the  cases  was  a  serious  objec- 
tion to  the  theory,  and,  finally,  the  milk  theory  also,  being  entirely 
unsupported  by  any  evidence,  had  to  be  abandoned. 

Contact  Infection'^  the  Apparent  Solution 

In  the  course  of  the  investigation  I  had  already  obser\'ed  some 
striking  examples  of  the  possible  methods  of  secondary  infection 
in  the  tenement  containing  cases  9,  12,  15,  16.  Some  of  the  other 
cases  were  also  plainly  secondary,  and  I  therefore  made  a  careful 
study  of  the  dates  of  the  several  cases  and  of  the  local  sanitary 
conditions.  As  a  result  I  was  finally  forced  to  conclude  that  from 
one  imported  case,  favored  by  the  peculiar  constitution  of  the 
little  community  and  its  habits,  the  fever  had  slowly  spread  by 
secondary  infection,  until  it  finally  reached  Front  Street.  The 
following  table  will  show  the  succession  of  cases,  and,  if  this  be 
read  in  connection  with  their  location  upon  the  map,  it  may  serve 

'  The  term  "  secondary  infection,"  as  used  in  this  account,  is  syn- 
onymous with  "  contact  infection." 


COMMUNICABLE   DISEASE 


277 


as  an  unusually  clear  and  interesting  example  of  the  growth  of  an 
epidemic  of  typhoid  fever  apparently  due  to  secondary  infection. 
It  is  noteworthy  that  many  of  the  patients  were  children. 


Number  of  the 

Date  of  the 

Number  of  the 

Date  of  the 

case 

case 

case 

case 

I 
2 

Aug.    i-s 
II 

13 
14 

Aug.  30 
Sept.  3 

3 
4 

13 
13 

15 
16 

4 

7 

S 
6 

14 

15 

17 
18 

12 
14 

7 
8 

16 
16 

19 

20 

IS 

16  (?) 

9 

20 

21 

20 

10 
II 

24 
26 

22 
23 

27 

29(?) 

12 

27 

24 

30 

/iTow  Contact  Infection  Occurs 

The  "  date  of  the  case  "  was,  as  usual,  either  the  date  "  of 
going  to  bed,"  or,  more  often,  of  the  "  physician's  first  visit." 
Some  of  the  victims  were  French,  some  Irish;  all  or  nearly  all 
went  to  the  same  school  and  attended  the  same  church.  The 
adults  of  the  two  nationalities  in  this  little  community  live  in 
friendly,  but  not  intimate,  relations;  the  children,  on  the  other 
hand,  play  constantly  together,  and  wander  freely  from  house  to 
house;  they  are  at  home  in  all  of  the  houses  in  which  there  are 
any  children.  On  High  and  Maple  streets  live  about  one  hundred 
and  fifty  people.  Children  abound;  and,  as  there  are  no  fences, 
and  because  it  is  the  custom,  they  mingle  freely,  playing  together 
and  passing  from  house  to  house.  The  families  are  of  that  grade 
in  which  food  always  stands  upon  the  table;  meals  are  irregular 
except  for  those  who  must  obey  the  factory  bell.  The  children 
play  awhile,  then  visit  the  privies,  and  with  unwashed  hands  finger 
the  food  upon  the  table.  Then  they  eat  awhile,  and  return  to  play. 
Or,  changing  the  order  of  things,  they  play  in  the  dirt  and  eat 
and  run  to  the  privy,  then  eat,  play  and  eat  again,  and  this  in 
various  houses  and  in  various  privies.  For  them,  so  long  as  they 
are  friendly,  all  things  are  common  —  dirt,  dinners  and  privies; 
and,  to  illustrate  how  secondary'  infection  may  go  on,  I  may  de- 
scribe in  detail  one  case  which  I  personally  witnessed.  A  whole 
family  (of  six  or  more)  was  in  one  room.  Four  of  them  had  the 
"  fever."     Two  of  these  were  children  in  the  prodromal  stage. 


278  A  MANU.\L  FOR  HEALTH  OFFICERS 

A  table  stood  by  the  window  covered  with  food,  prominent  among 
which  was  a  big  piece  of  cake.  It  was  early  September,  and  a 
very  warm  day;  but  every  window  was  shut  and  the  odor  was 
sickening.  Flies  innumerable  buzzed  about,  resting,  now  on  the 
sick  people,  now  on  the  food.  A  kind-hearted  neighbor  was  tend- 
ing the  baby.  By  and  by  one  of  the  children  having  the  fever 
withdrew  to  the  privy  probably  suffering  with  diarrhoea,  but 
soon  returning,  slouched  over  to  the  food,  drove  away  some  of  the 
flies  and  fingered  the  cake  listlessly,  finally  breaking  off  a  piece 
but  not  eating  it.  Stirred  by  this  example,  another  child  slid 
from  his  seat  in  a  half-stupid  way,  moved  to  the  table,  and,  taking 
the  same  cake  in  both  hands,  bit  off  a  piece  and  swallowed  it. 
The  first  boy  had  not  washed  his  hands,  and  if  the  second  boy 
suffered  from  secondary  infection,  I  could  not  wonder  at  it. 

This  was  one  case;  but  I  have  seen  so  often  the  table  of  food 
standing,  hours  long  in  the  kitchen  and  serving  as  one  station  in 
the  dirty  round  of  lives  like  these,  that  it  is  easy  for  me  to  under- 
stand how  dirt,  diarrha'a  and  dinner  too  often  get  sadly  confused. 
Personal  filth  is  apparently  the  principal  agent  of  secondary  infection. 

Thus  far  I  have  not  even  touched  upon  one  feature  of  the  life 
of  this  little  community,  which  deserves  careful  consideration. 
There  was  for  most  or  all  of  these  houses  a  sewer  connection  for 
the  sinks  but  not  for  the  privies.  Much,  perhaps  most,  of  the  garb- 
age found  its  way  into  the  privies.  These  had  been  obviously  in 
bad  condition,  and,  from  some,  filthy  streams  ran  down  between 
them  and  the  houses.  In  and  around  these  streams  the  children 
played.  Given  any  original  imported  case,  the  infection  might 
easily  have  reached  these  trickling  streams.  Children's  fingers 
might  thence  carry  the  germs  to  the  food,  and  thus  the  journey 
of  the  germs  from  one  living  intestine  to  another  be  completed. 
Or,  again,  given  in  such  a  community  an  imported  case  and  no 
disinfection,  as  was  the  condition  here  at  first.  The  importer 
while  in  the  early  stages  handles  with  unclean  hands  food  for 
others;  or  the  clothing  of  such  a  person  gets  infected  and  is  handled; 
there  need  be  then  no  difficulty  in  completing  the  history.  It 
follows  as  a  matter  of  course. 

Water-borae  Typhoid  Fever 
{Plymouth,  Pa.y 
Original  reference  to  this  epidemic:  1st  Ann.  Rpt.  State  Board  of 
Health  and  Vital  Statistics  of  Pennsylvania,  1886,  pp.  176-195. 

'  From  Whipple's  "  Typhoid  Fever,"  1908,  pp.  136-140.     This  work 
contains  accounts  of  tyi)hoid  epidemics  of  all  the  various  types. 


COMMUNICAIM.K    DISIsASK  279 

AmoiiR  the  typhoid  fever  c])i(lemics  wliich  have  occurred  in 
America  that  at  Plymouth,  J'a.,  deserves  first  mention,  partly  for 
the  reason  that  it  was  one  of  the  first  large  epidemics  where  the 
cause  was  definitely  ascertained,  and  partly  because  of  the  influ- 
ence which  the  lessons  taught  by  it  have  had  on  sanitary  science 
in  this  country. 

The  epidemic  occurred  in  the  sjjring  of  1885.  Plymouth  at 
that  time  was  a  mining  town  of  about  8000  inhabitants.  It  had 
a  public  water-supply  derived  from  a  stream  which  drained  an 
almost  uninhabited  water-shed,  and  the  water  was  stored  in  a 
series  of  four  small  reservoirs.  The  highest  of  these  reservoirs 
had  a  capacity  of  5,000,000  gallons;  the  next,  3,000,000;  the  next, 
1,700,000;  and  the  lowest,  nearest  the  city  and  used  as  a  distribut- 
ing reservoir,  300,000  gallons.  This  water-supply,  though  appar- 
ently satisfactory  in  quality,  was  not  sufificient  at  all  times  for  the 
needs  of  the  city,  and  occasionally  it  was  necessary  to  supplement 
it  by  pumping  from  the  Susquehanna  River.  Well  waters  were 
also  used  by  some  of  the  inhabitants.  As  it  turned  out,  neither  the 
well  water  nor  the  polluted  Susquehanna  water  played  any  part 
in  the  epidemic,  which,  through  the  efforts  of  Dr.  L.  H.  Taylor  of 
Wilkesbarre,  and  others,  was  found  to  have  been  caused  by  the 
"  pure  mountain  stream  "  supply  of  the  Plymouth  Water  Com- 
pany. 

It  is  unnecessary  to  follow  here  all  the  steps  by  which  the  epi- 
demic was  traced  to  its  origin;  it  will  be  simpler  to  recite  the  perti- 
nent events  chronologically,  and  this  will  also  indicate  more  clearly 
the  relation  between  cause  and  effect. 

The  Original  Case 

In  an  open  clearing  near  the  banks  of  the  stream  and  just  below 
the  upper  reservoir,  there  existed  one  of  the  few  houses  on  the 
water-shed.  The  man  who  occupied  this  house  went  to  Philadel- 
phia on  Dec.  24,  1884,  and  on  Jan.  2,  1885,  returned  home  ill 
with  typhoid  fever.  It  was  a  severe  case.  The  patient  was  in 
bed  for  many  weeks.  By  the  first  of  March  he  was  convalescent, 
but  a  relapse  occurred,  and  it  was  the  middle  of  April  before  the 
physician's  visits  were  discontinued.  "  During  the  course  of  his 
illness,  his  night  dejecta  were  thrown  without  disinfection  upon 
the  snow  and  frozen  ground,  toward  and  within  a  few  feet  of  the 
edge  of  the  high  bank  which  sloped  precipitously  down  to  the 
stream  supplying  the  town  with  water.  .  .  .  The  dejecta  passed 
during  the  day  were  emptied  into  a  privy  a  little  farther  back, 
the  contents  of  which   laj-  almost  upon  the  surface  of  the  ground, 


28o  A  MANUAL  FOR  HEALTH  OFFICERS 

so  that  at  the  first  thaw  or  rain  they  too  would  pass  down  the 
sloping  bank  and  into  the  stream." 

Until  the  latter  part  of  March  the  ground  remained  frozen  and 
covered  with  snow,  and  under  these  conditions  it  is  improbable 
that  the  dejecta  reached  the  water  of  the  stream.  But  during  the 
last  week  in  March  there  was  a  thaw,  the  air  temperature  increased 
rapidly  until,  on  April  4,  the  ma.ximum  was  70  degrees.  During 
these  few  days  of  warm  weather  the  accumulated  dejecta  of  many 
weeks  probably  found  their  way  into  the  stream  which  supplied 
the  town  with  water. 

Infection  of  Public  Water  Supply 

On  the  evening  of  March  26,  the  superintendent  of  the  water 
company  visited  the  reservoirs  and  found  that  the  two  lower  ones 
were  almost  empty,  while  the  one  just  below  the  house  where  the 
typhoid  patient  lived  was  filling  rapidly.  He  found,  however, 
that  the  short  pipe  which  allowed  the  water  to  discharge  from  the 
bottom  of  this  reservoir  into  the  stream  leading  to  the  reservoir 
below  it  was  frozen,  and  he  caused  a  fire  to  be  built  to  melt  the  ice 
in  the  pipe.  This  done,  the  water  flowed  from  the  bottom  of  this 
reservoir  down  through  the  two  reservoirs  below  it,  and  thence 
into  the  town,  where  in  all  probability  it  first  arrived  some  time 
between  March  28  and  April  4  or  5  —  that  is,  from  two  days  to  a 
week  after  it  was  let  down  from  the  third  reservoir. 

Magnitude  and  Lessons  of  the  Epidemic 

The  first  case  of  typhoid  fever  in  the  town  occurred  on  April  9, 
and  from  this  time  on  the  disease  spread  rapidly.  During  the 
week  beginning  April  12,  from  50  to  100  new  cases  appeared  daily, 
and  it  is  said  that  on  one  day  200  new  cases  were  reported.  All 
classes  of  people  were  attacked  in  all  parts  of  the  town,  until, 
before  the  epidemic  ceased,  out  of  the  8000  inhabitants,  1 104  con- 
tracted the  disease,  and  114  died. 

This  epidemic,  as  Dr.  Taylor  said  in  his  report,  "  was  one  of  the 
most  remarkable  ones  in  the  history  of  typhoid  fever,  and  taught 
important  lessons,  though  at  a  fearful  cost.  One  is,  that  in  any 
case  of  typhoid  fever,  no  matter  how  mild,  or  how  far  removed 
from  the  haunts  of  men,  the  greatest  possible  care  should  be  exer- 
cised in  thoroughly  disinfecting  the  poisonous  stools.  The  origin 
of  all  this  sorrow  and  desolation  occurred  miles  away  on  the  moun- 
tain side,  far  removed  from  the  populous  town,  and  in  a  solitary 
house  situated  upon  the  banks  of  a  swift-running  stream.  The 
attending  physician  did  not  know  that  this  stream  supplied  the 


COMMUNICABLE  DISEASE  281 

reservoirs  with  drinking-water.  Here,  if  at  any  place,  it  might 
seem  excusable  to  take  less  than  ordinary  jjrecau lions;  but  the 
secjuel  shows  that  in  every  case  the  most  rigid  attention  to  detail 
in  destroying  these  poisonous  germs  should  be  enjoined  upon 
nurses  and  others  in  charge  of  typhoid  fever  patients,  while  the 
history  of  this  epidemic  will  but  add  another  to  the  list  of  such 
histories  which  should  serve  to  imjjress  medical  men,  at  least,  with 
the  great  necessity  for  perfect  cleanliness  —  a  lesson  which  man- 
kind at  large  is  slow  to  learn." 

The  epidemic  is  interesting  to  bacteriologists  from  the  fact  that 
it  throws  some  light  upon  the  ability  of  the  typhoid  bacillus  to  sur- 
vive the  apparently  unfavorable  conditions  of  winter.  Some  of  the 
bacilli  at  least  must  have  lived  and  retained  their  virulence  in  the 
frozen  fecal  matter  for  many  weeks. 
The  financial  loss  in  this  epidemic  has  been  estimated  at  more  than 
half  a  million  dollars.' 

Milk-borne  Scarlet  Fever 

{Norwalk,  Conn.y 
In  November,  1897,  an  unusual  number  of  cases  of  scarlet  fever 
occurred  in  Norwalk.  Population  of  Norwalk,  South  Norwalk 
and  East  Norwalk,  22,000.  Previous  to  October  25  scarlet  fever 
had  been  reported  as  follows:  August,  no  cases;  September,  5 
cases;  October  10,  one  case.  The  source  of  infection  in  most  of 
these  cases  had  been  traced. 

Number  and  Distribution  of  Cases 

Between  October  25  and  November  9,  29  cases  developed.  The 
29  cases  were  distributed  in  25  families  and  24  houses.  School 
infection  was  eliminated.  Many  cases  did  not  attend  school,  and 
some  were  in  families  where  they  had  no  school  children.  The 
cases  were  widely  separated;  17  of  the  infected  houses  were  in 
South  Norwalk,  3  in  Norwalk  and  4  in  East  Norwalk.  The 
families  were  of  different  social  positions  and  contact-infection 
seemed  improbable.  The  only  factor  in  common  to  practically 
all  of  the  cases  was  the  milk  supply.     Twenty-seven  out  of  the  29 

1  Dr.  M.  S.  French,  quoted  by  Sedgwick  in  "  Sanitary  Science  and 
Public  Health." 

2  Account  and  diagram  taken  from  Trask,  in  "  Milk  and  Its  Rela- 
tion to  the  Public  Health,"  Bull.  56,  Hyg.  Lab.  of  U.  S.  Public  Health 
Service,  1909,  pp.  33,  34.  Original  reference:  Smith  (Herbert  E.), 
Rpt.  Connecticut  State  Board  of  Health,  1897,  p.  259. 


282  A  MANUAL   FOR  HEALTH  OFFICERS 

obtained  milk  from  one  dealer,  H.  The  other  two  were  in  one 
family  in  East  Norwalk;  they  were  a  girl  of  I2  and  a  boy  of  9 
years,  and  were  taken  ill  on  November  7  and  9,  respectively. 
They  had  no  connection  with  the  milk  route,  nor  could  their  in- 
fection be  traced  to  any  source. 

The  estimated  daily  supply  of  milk  in  Norwalk  was  3500  quarts. 
Dealer  H  furnished  450  quarts,  or  about  one-eighth  of  the  whole, 
whereas  he  had  twenty-seven  twenty-ninths  of  the  scarlet  fever 
cases  on  his  route. 

How  Milk  Became  Injected 

II  bouglu  his  milk  from  three  producers.  There  were  no  cases 
of  disease  in  the  family  of  the  milk  dealer  nor  in  those  of  two  of 
the  producers,  A  and  B,  but  on  the  third  producing  farm,  K,  a 
case  of  scarlet  fever  was  found.  This  farm  was  in  the  Bald  Hill 
district.  The  district  school  had  opened  September  7  with  a 
registration  of  23  pupils.  On  September  20  one  of  the  pupils  fell 
ill  with  scarlet  fever;  other  cases  followed,  and  the  school  was 
closed  October  19.  In  all  there  were  20  cases,  all  in  school  children 
or  in  those  coming  in  contact  with  them.  Two  of  the  above  cases, 
living  near  farm  K,  were  exceedingly  mild  and  frequently  visited 
and  played  at  this  farm  with  K's  son,  a  lad  of  4  years.  This  son 
broke  out  with  a  scarlatinous  rash  October  24. 

Milk  from  this  farm  was  carted  to  Norwalk  and  all  of  it  sold  to, 
and  delivered  by,  dealer  H,  who  placed  the  cans  of  milk  from  K 
in  his  wagons  with  that  from  the  other  two  producers,  A  and  B. 
No  attempt  was  made  to  keep  the  cans  separate,  and,  therefore, 
one  day  part  of  his  customers  might  receive  K's  milk  and  the  next 
day  it  would  be  delivered  to  others.  H  supplied  about  300  families, 
of  which  24  were  invaded.  The  sale  of  this  milk  was  stopped 
November  7.     The  number  of  cases  and  the  dates  on  which  they 


Explanation  of  Chart  3 

A,  B  and  K  are  dairy  farms  selling  their  product  to  retail  milk  dealer 
H.  K  is  the  farm  on  which  a  case  of  scarlet  fever  occurred  antedating 
the  outbreak  in  Norwalk. 

The  large  square  TOWN  represents  the  city  of  Norwalk. 

H  is  the  retail  milk  dealer  among  whose  customers  all  cases  but  two 
occurred.  The  dash  lines  represent  11 's  milk  route,  and  each  dot  is  a 
case  of  scarlet  fever. 

C,  D,  E,  F,  G,  I  and  J  are  other  dairymen  having  routes  in  Norwalk. 
The  lines  extending  from  them  into  the  city  represent  their  milk  routes 
and  are  introduced  to  show  their  freedom  from  the  disease. 


COMMUNICAIiLI':    DISIvASIC 


283 


Chart  3. 
(From  Trask) 

Showing  Relation  of  Milk  Routes  to  Scarlet  Fever  Cases  During  Out- 
break at  Norwalk,  Conn.,  1897.     (For  explanation  see  p.  2S2.) 


2S4  A  MANUAL  FOR   HEALTH  OFFICERS 

occurred  would  indicate  that  the  milk  was  not  continuously  in- 
fected. During  the  outbreak  several  cases  of  sore  throat  occurred 
among  users  of  H's  milk,  which  may  possibly  have  had  some 
casual  relation  to  the  infectious  milk.     [  See  Chart  3.] 

It  would  seem  that  cases  of  scarlet  fever  belonging  to  the  school 
outbreak  and  visiting  the  dairy  farm,  and  possibly  also  the  boy  on 
the  farm,  infected  from  his  plajmates,  were  the  source  or  sources 
rendering  the  milk  infective.  The  relation  here  of  the  two  out- 
breaks is  of  interest,  the  one  spread  by  school  contact  being  the 
original  source  of  the  milk  epidemic. 

Shellfish  Infection  (Typhoid  Fever) 

The  chief  example  of  an  epidemic  due  to  infected  shellfish  is  that 
of  Middletown,  Conn.  Between  October  20  and  November  9  there 
occurred  among  persons  connected  with  Wesleyan  University  at 
Middletown  25  cases  of  typhoid  fever,  4  of  which  proved  fatal.  The 
epidemic  was  investigated  by  Dr.  H.  W.  Conn,  who  found  that  the 
persons  in  question  had  taken  part  in  banquets  held  October  12,  where 
the  only  article  of  food  common  to  the  cases  was  oysters  taken  from  a 
certain  source.  On  tracing  these  oysters  back  it  was  found  that  they 
had  been  "  floated  "  (i.e.,  placed  to  fatten  in  brackish  water)  in  the 
water  of  a  sewage-polluted  estuary.  It  was  therefore  concluded  that 
this  was  the  source  of  the  epidemic.  It  was  estimated  that  25  per  cent 
of  those  who  partook  of  the  dinners  were  made  ill  with  typhoid  fever 
or  intestinal  disorder. ^ 

Milk-borne  Infection  Due  to  a  Carrier  (Typhoid  Fever) 

{New   York  CityY 
Early  in  February,  19 10,  our  attention  was  arrested  by  the  fact 
that  on  one  day  nine  cases  of  typhoid  fever  were  reported  from  a 

1  See  Whipple,  "  Typhoid  Fever,"  1908. 

2  Bolduan  and  Noble,  "  A  Localized  Outbreak  of  Typhoid  Fever 
Traced  to  Milk  Infected  by  a  Bacillus  Carrier;  also  a  Case  of  Labora- 
tory Typhoid  Fever  Contracted  from  the  Cultures,"  N.  Y.  Med.  Jour.. 
1912  (reprint  of  Dept.  of  Health  of  the  City  of  New  York).  (Italics 
are  those  of  present  author.)  Cf.  account  by  same  authors:  "  A 
Typhoid  Bacillus-Carrier  of  Forty-Six  Years'  Standing,  and  a  Large 
Outbreak  of  Milk-borne  Typhoid  Fever  Traced  to  This  Source,"  Jour. 
Am.  Med.  Assti.,  Jan.  6,  1912,  vol.  Iviii,  pp.  7-9  (reprinted  by  N.  Y, 
City  Dept.  of  Health);  also  H.  W.  Hill,  "All  the  Typhoid  of  a  Com- 
munity for  Five  Years  from  a  Carrier  through  Milk,"  Am.  Jour.  Pub. 
Health,  1914,  vol.  IV,  no.  8,  p.  667. 


COMMUNICABLE    IJISIOASIC  285 

small  district  on  the  upper  West  Side  (lioroii^li  of  Manhattan). 
Four  of  the  cases  were  in  149th  Street,  two  in  122nd  Street  and 
the  rest  in  the  section  between.  The  followinjj  day  six  additional 
cases  were  reported  from  this  district,  and  after  this,  for  several 
weeks,  each  day  brought  more  cases  to  light.  Careful  investi- 
gations were  at  once  instituted  and  these  showed: 

1.  That  the  outbreak  was  confined  to  a  comparatively  small 
part  of  the  city. 

2.  That  practically  all  of  the  patients  had  been  supplied  with 
milk  from  one  particular  milk  company. 

3.  That  with  the  exception  of  the  municipal  water  supply,  no 
other  factor  than  milk  was  common  to  all  of  the  cases. 

4.  That  the  date  of  onset  in  most  of  the  cases  was  the  last  week 
in  January. 

The  localized  character  of  the  outbreak  at  once  excluded  the 
water  supply  as  the  source  of  the  infection.  The  milk  in  question 
was  supplied  by  one  of  the  large  milk  companies,  and  was  almost 
all  obtained  in  the  northern  part  of  New  York  State  in  the  vicinity 
of  Lake  Champlain  and  from  the  adjacent  part  of  Vermont.  All 
this  milk  was  bottled  in  the  country  and  was  raw  milk.  Several 
inspectors  were  at  once  ordered  by  telegraph  to  investigate  the 
various  creameries  which  had  shipped  milk  to  the  infected  district 

during  January,  and  it  was  found  that  in  P ,  where  one  of 

the  creameries  was  located,  a  series  of  six  cases  of  typhoid  fever 
had  suddenly  appeared  practically  simultaneously  with  the  cases 
being  studied  in  New  York  City. 

Meanwhile  additional  cases  were  being  reported  in  the  city  from 
the  district  mentioned  on  the  upper  West  Side,  and  almost  all  the 
patients  were  found  to  be  users  of  the  suspected  milk.  The  few 
exceptions  proved,  in  one  or  two  instances,  to  be  cases  incorrectly 
diagnosticated  as  typhoid  fever,  in  other  instances  cases  contracted 
out  of  town.  It  is  probable  that  some  of  the  later  cases  were 
secondarily  infected,  though  no  connection  with  previous  cases 
could  be  discovered.  The  total  number  of  cases  belonging  to  the 
outbreak  was  forty-four. 

It  is  well  known  that  in  outbreaks  of  typhoid  fever  due  to  milk 

infections  a  large  proportion  of  children  are  attacked.     This  was 

true  of  the  present  outbreak,  as  can  be  seen  from  the  following 

table  showing  the  age  distribution  of  the  cases: 

5  years  and  under      s'to  10      10  to  15      15  to  20      20  to  25      25  to  30      Over  30       Total 

6  648114544 

Plotting  the  dates  of  onset  in  the  form  of  a  cur\-e,  as  has  been 
done  in  the  chart,  we  get  the  impression  that  the  infecting  agent 


286  A  MANUAL   FOR   HEALTH  OFFICERS 

.  operated  several  times.  While  we  have  been  unable  to  prove  that 
the  milk  was  thus  repeatedly  infected,  it  is  suggestive  to  note  that 
the  onsets  of  the  P cases  were; 

January  20th  —  one  case. 

January-  24ih  —  one  case. 

February  1st  —  three  cases. 

February  7th  —  one  case. 

Returning  now  to  the  P cases,  it  was  found  that  the  six 

cases  occurred  in  homes  supplied,  in  each  instance,  with  milk  from 
the  shipping  station,  "  creamery,"  in  question.  This  is  particularly 
important  because  no  milk  is  allowed  to  be  sold  from  the  creamery 
for  local  consumption.  The  employees  of  the  creamery,  however, 
have  been  allowed  to  supply  their  households  at  wholesale  prices, 
and  the  infected  households  were  each  of  them  thus  supplied. 

Discovery  of  Original  Case  {Carrier) 

There  was  no  question,  therefore,  that  the  milk  shipped  from 
was  the  cause  of  the  New  York  city  outbreak,  and  ac- 


cordingly orders  were  issued  prohibiting  further  shipments  from 
that  creamery.  Meantime,  careful  investigations  were  made  in 
order  to  discover  the  ultimate  cause  of  the  infection.  The  cream- 
ery was  carefully  inspected  and  all  the  employees  were  interrogated 
in  their  homes.  Each  of  the  forty-five  dairies  sending  milk  to 
this  creamery  was  visited,  and  all  members  of  the  household 
including  the  help  were  questioned  as  to  a  possible  typhoid  infec- 
tion; a  large  number  of  blood  tests  were  made  on  all  who  gave  a 
history  of  recent  illness,  no  matter  of  what  nature;  in  short,  every 
conceivable  source  of  infection  was  thoroughly  investigated.  The 
result  was  the  discovery  of  a  dairy  farmer  who  gave  a  history'  of 
six  cases  of  typhoid  fever  on  his  farm  in  1904,  one  case  in  1907,  and 
one  case  in  1908.  The  dairyman  represented  the  last  of  the  six 
cases  in  1904,  and  was  now  the  only  person  on  the  farm  who  had 
had  the  disease.  Specimens  of  his  stools  were  collected  and  ex- 
amined for  typhoid  bacilli.  The  examinations  disclosed  the  pres- 
ence of  enormous  numbers  of  living  typhoid  bacilli;  in  other 
words,  the  man  was  a  "  bacillus  carrier."  Needless  to  say,  the 
bacilli  were  tested  with  typhoid  agglutinating  serum  and  also  as 
to  their  cultural  characteristics.  They  proved  to  be  typical,  as 
can  be  seen  from  an  examination  of  the  laboratory  data  below. 
The  order  excluding  the  milk  was  thereupon  modified  to  apply 
only  to  milk  from  this  one  dair^',  and  regular  shipments  from  the 
creamery  were  resumed.  In  view  of  all  the  circumstances  men- 
tioned, the  fact  that  no  more  cases  developed,  except  during  the 


COMMUNICAl'.IJ';    DISKASK  287 

incubation  period,  after  ihe  milk  was  slopijcd,  and  that  no  cases 
occurred  after  the  creamery  was  all(iwed  to  resume  shijjments,  it 
is  evident  tliat  this  carrier  constituted  the  source  of  infection. 


Intermittent  Carriage  of  Germs 

A  number  of  questions  at  once  arise.     Since  the  dairy  farmer 

had  been  sending  milk  to  the  P creamery  regularly  during 

.  the  previous  two  years,  why  did  not  the  P milk  show  evi- 
dences of  typhoid  infection  prior  to  the  present  outbreak?  How 
did  the  milk  actually  become  infected  from  the  stools  of  the  dairy 
farmer?     How  can  such  infections  be  guarded  against? 

In  considering  the  first  of  these  questions,  it  is  important  to 
remember  that  recent  bacteriological  investigations  have  shown 
that  germ  carriers  may  be  divided  into  two  classes,  chronic  and 
intermittent.  In  the  latter  the  bacilli  may  often  be  absent  for 
considerable  periods  at  a  time,  only  to  reappear  in  undiminished 
numbers  at  a  later  time.  Even  in  the  chronic  germ  carriers,  if 
repeated  examinations  are  made,  the  bacilli  may  be  present  at 
one  time  and  absent  another.  This  is  well  shown  in  the  report  on 
repeated  examinations  of  the  well-known  typhoid  carrier,  "Ty- 
phoid Mary,"  who  was  under  observation  for  some  three  years.^ 

The  carrier  whom  we  discovered  in  P was  apparently  one  of 

the  intermittent  variety,  for  we  were  subsequently  informed  that 
following  our  report  concerning  the  finding  of  typhoid  bacilli  in 
the  faeces,  sixteen  specimens  were  sent  to  another  laboratory'  and 
no  typhoid  bacilli  found.  In  fact  this  led  to  our  identification  of 
the  bacilli  being  questioned,  but,  as  has  already  been  shown,  we 
were  able  to  confirm  our  findings  most  conclusively  in  an  unex- 
pected manner.  Another  and  perhaps  the  main  factor  in  deter- 
mining the  frequency  with  which  a  typhoid  bacillus  carrier  will 
infect  the  things  he  handles,  lies  in  the  degree  of  personal  cleanli- 
ness of  the  individual. 

It  was  impossible  to  discover  how  the  milk  was  actually  in- 
fected. The  construction  of  the  dairy  barn,  the  w-ater  supply, 
location  of  privy  and  cesspool  were  all  satisfactory.  Moreover,  it 
is  unnecessary'  to  trace  the  path  of  the  typhoid  bacilli  from  the 
carrier's  intestinal  tract  to  the  milk  sent  to  the  creamer^-.  No 
matter  how  cleanly  in  his  habits,  such  a   germ    carrier  on   a   dairy 

^  Noble  and  Pratt,   Collected  Studies  from  the  Research  Laboratory, 
Department  of  Health,  City  of  New  York,  iv,  p.  188,  1908-1909. 


288  A  MANUAL  FOR  HE.ALTH  OFFICERS 

farm  is  always  a  menace;^  sooner  or  later,  through  some  oversight 
the  necessary  combination  of  circumstances  presents  itself  and  in- 
fection of  others  occurs.  How  Can  Such  Infections  be  Guarded 
Against^ 

The  answer  to  this  last  question  is  extremely  difficult.  [The 
author  then  states  the  impossibility  of  examining  the  excreta  of 
the  large  number  of  individuals  engaged  in  handling  the  milk 
shipped  into  New  York  City  in  order  to  detect  bacillus  carriers.] 
Some  advance  will  be  made  when  every  person  who  has  been  known 
to  have  had  typhoid  fever  and  who  is  engaged  in  producing  or 
handling  milk  must  undergo  the  necessary  bacteriological  ex- 
aminations in  order  to  prove  that  he  is  not  a  bacillus  carrier.  In 
engaging  dairy  and  creamery  help,  or  other  persons  coming  into 
contact  with  milk  sold  to  the  public,  inquiry  concerning  a  previous 
history  of  typhoid  fever  should  be  made  and  action  taken  accord- 
ingly. It  may  be  found  feasible  to  enforce  some  such  requirements 
for  the  exclusion  of  bacillus  carriers  from  the  dairy  industry  in  the 
case  of  the  better  grades  of  milk,  those  selling  at  retail  for  12  cents 
a  quart  and  more.  So  far  as  the  ordinary  milk  is  concerned,  how- 
ever, .  .  .  it  seems  impossible  to  guard  against  this  form  of  infection 
in  any  other  way  than  by  efficient  pasteurization. 

Milk-borne  Septic  Sore  Throat 

In  recent  years  a  number  of  epidemics  of  tonsillitis  or  septic  sore 
throat  have  been  reported  and  in  some  instances  very  carefully  worked 
out.  Unfortunately  the  conclusions  as  to  the  origin  of  these  outbreaks 
have  not  been  unanimous  or  positive.  There  is  evidence  to  indicate 
that  they  are  due  to  inflammatory  conditions  of  the  udders  of  dairy 
cows,  but  the  identity  of  the  bacteria  found  in  such  conditions  and  those 
found  in  the  throats  of  the  victims  has  not  been  conclusively  estab- 
lished; and  on  the  other  hand  there  is  reason  for  suspecting  human 
carriers  of  the  pathogenic  organism. 

An  extensive  epidemic  in  Boston  and  environs  was  investigated  by 
Winslow.2  1043  cases  were  studied.  The  epidemic  was  explosive  in 
character,  the  majority  of  cases  occurring  within  a  week.  The  cases 
followed  one  particular  milk  supply.  Cases  of  septic  sore  throat  were 
numerous   in   the   region   from    which   this   supply   was   derived.     No 

^  Bolduan  and  Noble,  Journal  of  the  American  Medical  Association, 
Iviii,  1912. 

'  Winslow,  "  An  Outbreak  of  Tonsillitis  or  Septic  Sore  Throat  in 
Eastern  Massachusetts,  and  Its  Relation  to  an  Infected  Milk  Supply," 
Jour.  Inf.  Diseases,  1912,  vol.  x,  no.  i,  p.  73. 


COMMUNICABLE   DISEASE  289 

record  was  obtained  of  any  well-defined  case  of  tonsillitis  in  direct  con- 
tact with  the  milk,  but  it  was  concluded  on  the  circumstantial  evidence 
that  the  actual  infection  was  due  to  a  carrier  case.  No  cattle  disease 
was  known  to  have  occurred  on  any  of  the  farms.  The  supply  was 
clean  and  carefully  handled.  The  investigator  concludes  that  even  a 
most  carefully  supervised  supply  is  open  to  the  clanger  of  grave  infec- 
tion from  carrier  or  unrecognized  cases  of  disease,  and  puts  forth  as 
"  the  only  real  safeguard  against  such  catastrophes  "  "  pasteurization, 
carried  out  by  the  holding  system  and  preferably  in  the  final  packages." 

In  February  and  March,  1912,  there  occurred  in  Baltimore  an  epi- 
demic of  "  throat  infection  associated  with  or  followed  by  one  or  more 
of  the  following  conditions:  cervical  adenitis,  septiceemia,  peritonitis, 
and  erysipelas.  Bacteriological  examinations  were  made  of  the  milk 
supply  involved,  of  the  milk  at  the  farms  and  of  the  throats  of  em- 
ployees and  cases.  The  milk  had  been  supposedly  pasteurized  by  the 
flash  process  (stated  as  158°  to  165°  F.  for  25  to  5  minutes),  but  this 
proved  to  have  been  inefficient.  In  the  various  bacteriological  exam- 
inations the  following  organisms  were  found:  diplococcus  pneumoniae, 
streptococcus  epidemicus  (few)  and  streptococcus  pyogenes.  From 
these  examinations^  the  investigator  draws  a  reasonable  certainty  "that 
the  outbreak  .  .  .  was  largely  due  to  milk  that  had  not  been  thoroughly 
pasteurized." 

Epidemics  have  also  been  reported  from  Chicago,  Homer  and  Cort- 
land (N.  Y.),-  and  other  places  in  this  countr>\  Numerous  outbreaks 
have  occurred  in  Great  Britain  and  have  been  clearly  traced  to  infected 
milk  supplies.  Septic  sore  throat  is  therefore  by  no  means  rare  as  a 
milk-borne  infection  and  is  one  of  the  serious  dangers  that  surround  a 
raw  milk  supply. 

SUMMARY  OF  MILK-BORNE   EPIDEMICS 

As  illustrating  the  more  common  ways  in  which  milk  may  be  infected 
the  following  summary '  is  of  interest. 

Of  the  179  typhoid  epidemics  reported  as  spread  by  milk,  com- 
piled by  the  writer,  ...  all  cases  enumerated  in  the  outbreak  were 
reported  as  living  in  houses  supplied  with  the  suspected  milk  in 

1  Hachtel,  "  Bacteriological  Investigation  of  an  Outbreak  of  Septic 
Sore  Throat  in  Baltimore  "  (Abstract),  Afn.  Jour.  Pub.  Health,  1913, 
vol.  iii,  no.  8,  p.  780.  The  epidemic  was  also  studied  by  officials  of 
the  U.  S.  Public  Health  Service. 

2  Jour.  Inf.  Diseases,  Jan.,  1914;  and  Rpt.  of  N.  Y.  Milk  Committee 
for  1913,  p.  30. 

^  Trask,  in  Bull.  56,  Hyg.  Lab.  U.  S.  Pub.  Health  Service,  1909. 


290  A  MANUAL   FOR   HMM/IH   OFFICERS 

96  of  the  ei)idcmics;  a  case,  suffering  from  tlie  disease  at  such  a 
time  as  to  have  been  the  possible  source  of  infection,  was  found  at 
the  producing  farm,  distributing  dajry  or  milk  shop  in  113  cases; 
the  outbreak  was  supposed  to  have  been  due  to  bottles  returned 
from  infected  households  and  refilled  and  distributed  without 
previous  sterilization  in  4  cases. 

Of  the  23  diphtheria  epidemics  reported  as  spread  by  milk  .  .  . 
cases  of  the  diseases  occurred  at  the  producing  farm,  distributing 
dairy  or  milk  shop  at  such  a  time  as  to  have  been  the  possible 
cause  of  the  outbreak  in  18  cases;  the  diseased  person  milked  ihe 
cows  in  4;  the  same  person  nursed  the  sick  and  handled  the  milk 
in  I ;  the  outbreak  was  supposed  to  be  due  to  disease  of  the  cows 
in  2;  all  c^ses  of  the  disease  were  reported  as  living  in  households 
supplied  with  the  suspected  milk  in  15  instances;  measures  taken 
upon  the  presumption  that  milk  was  the  carrier  of  infection  were 
reported  as  followed  by  subsidence  of  the  outbreak  in  5  cases; 
the  Klebs-Loeffler  bacillus  was  isolated  from  the  suspected  milk  in 
2  of  the  epidemics. 

Of  the  51  scarlet  fever  epidemics  reported  as  spread  by  milk, 
compiled  by  the  writer,  ...  all  cases  enumerated  in  the  out- 
break were  reported  as  living  in  houses  supplied  with  the  sus- 
pected milk  in  27  of  the  epidemics;  a  case  suffering  from  the 
disease  at  such  a  time  as  to  have  been  the  possible  source  of  infec- 
tion was  found  at  the  producing  farm,  the  distributing  dairy  or 
milk  shop  in  35  cases;  the  outbreak  was  supposed  to  have  been 
due  to  bottles  returned  from  infected  households  and  refilled  with- 
out previous  sterilization  in  3  cases;  the  diseased  person  or  per- 
sons were  mentioned  as  handling  the  milk  or  milk  utensils  in  3; 
the  sick  milked  the  cows  in  12;  the  same  person  nursed  the  sick 
and  handled  the  milk  in  i ;  same  person  nursed  sick  and  milked 
cows  in  I ;  the  outbreak  was  supposed  to  be  due  to  disease  of  the 
cow  in  2;  it  was  reported  that  measures  taken  upon  the  presump- 
tion that  milk  was  the  cause  of  the  epidemic  were  followed  by 
abatement  of  the  outbreak  in  22  cases. 
In  138  epidemics  of  milk-borne  typhoid  fever  collected  by  Busey  and 
Kober  the  following  data  are  given  :i 

In  109  instances  there  is  evidence  of  the  disease  having  prevailed 
at  the  farm  or  dairy.  In  54  epidemics  the  poison  reached  the  milk 
by  soakage  of  the  germs  into  the  well  water  with  which  the  utensils 
were  washed  and  in  13  of  these  instances  the  intentional  dilution 
with  polluted  water  is  admitted.  In  6  instances  the  infection  is 
attributed  to  the  cows  drinking  or  wading  in  sewage-polluted  water. 
1  Quoted  by  Trask,  loc.  cii. 


COMMUNICABLE  DISEASE  291 

In  three  instances  the  infection  was  spread  in  ice  cream  prepared 
on  infected  premises.  In  21  instances  the  dairy  emjjioyees  also 
acted  as  nurses.  In  6  instances  the  patients  while  suffering  from 
a  mild  attack  of  enteric  fever,  or  during  the  first  week  or  ten  days 
of  their  illness  continued  at  work  and  those  of  us  who  are  familiar 
with  the  personal  habits  of  the  average  dairy  boy  will  have  no 
difficulty  in  surmising  the  manner  of  direct  digital  infection.  In 
one  instance  the  milk  tins  were  washed  with  the  same  dishcloth 
used  among  the  fever  patients.  In  one  instance  the  disease  was 
attributed  to  an  abscess  of  the  udder,  in  another  to  a  teat  eruption, 
and  in  no.  81  to  a  febrile  disorder  in  the  cows.  Nos.  85,  103,  120, 
and  127  were  creamery  cases.  In  no.  96  the  milk  had  been  kept 
in  the  sick  room. 
In  28  epidemics  of  milk-borne  diphtheria  collected  by  the  same 
authorities,  the  following: 

In  10  instances  diphtheria  existed  at  the  farm  or  dairy,  and  in 
ID  instances  the  disease  is  attributed  directly  to  the  cows  having 
garget,  chapped  and  ulcerative  affections  of  the  teats  and  udder, 
while  in  no.  13  the  cows  were  apparently  healthy  but  the  calves 
had  diarrhoea.  In  no.  23  one  of  the  dairy  maids  suffered  from  a 
sore  throat  of  an  erysipelatous  character,  and  in  no.  27  the  patient 
continued  to  milk  while  suffering  from  diphtheria.  In  no.  28  one 
of  the  drivers  of  the  dairy  wagons  was  suffering  from  a  sore  throat. 
And  in  74  epidemics  of  milk-borne  scarlet  fever,  the  following: 

In  41  instances  the  disease  prevailed  either  at  the  milk  farm  or 
dairy.  In  6  instances  persons  connected  with  the  dairy  either 
lodged  in  or  had  visited  infected  houses.  In  no.  12  the  milkman 
had  taken  his  can  into  an  infected  house.  In  20  instances  the  in- 
fection was  attributed  to  disease  among  the  milch  cows;  in  4  of 
these  the  puerperal  condition  of  the  animal  is  blamed.  In  9  in- 
stances disease  of  the  udder  or  teats  was  found.  In  one  instance 
the  veterinarian  diagnosed  a  case  of  bovine  tuberculosis.  In  6 
instances  there  was  loss  of  hair  and  casting  of  the  skin  in  the 
animal.  In  no.  68  the  cattle  were  found  to  be  suffering  more  or 
less  from  febrile  disturbance.  In  10  instances  the  infection  was 
doubtless  conveyed  by  persons  connected  with  the  milk  business, 
while  suffering  or  recovering  from  an  attack  of  the  disease,  and  in 
at  least  8  cases  by  persons  who  also  acted  as  nurses.  In  three 
instances  the  milk  had  been  kept  in  the  cottage  close  to  the  sick 
room.  In  no.  15  the  cows  were  milked  into  an  open  tin  can  which 
was  carried  across  an  open  yard  past  an  infected  house,  and  in 
no.  53  the  milkman  had  wiped  his  cans  with  white  flannel  cloths 
(presumably  infected)  which  had  been  left  in  his  barn  by  a  peddler. 


292  A  MANUAL  FOR  HEALTH  OFFICERS 

Nos.  21  and  44  appear  to  have  been  instances  of  mixed  infection  of 
scarlet  fever  and  diphtheria. 
It  may  be  added  that  experience  has  shown  that  good  general  sani- 
tary conditions  by  no  means  necessarily  protect  a  milk  supply  if  a 
source  of  infection  is  present. 

Points  of  Interest  in  Reporting  Milk  Epidemics^ 

In  reporting  milk  epidemics  some  of  the  points  of  special  inter- 
est are  the  following: 

1.  The  number  of  cases  of  the  disease  existing  in  the  involved 
territory  during  the  time  covered  by  the  epidemic. 

2.  The  number  of  houses  invaded  by  the  disease. 

3.  The  number  of  invaded  houses  supplied  in  whole  or  in  part, 
directly  or  indirectly,  by  the  suspected  milk. 

4.  The  number  of  cases  occurring  in  invaded  houses  so  supplied. 

5.  The  number  of  houses  supplied  with  the  suspected  milk. 

6.  The   relative    proportion    of    houses   so    supplied    to   those 
supplied  by  other  dairies. 

7.  The  time  covered  by  the  epidemic. 

8.  The  location  of  the  case  or  cases  from  which  the  milk  became 
contaminated. 

9.  The  relation  of  the  original  case  to  the  milk. 

10.  The  time  relation  of  the  original  case  to  the  epidemic. 

11.  The  special  incidence  of  the  disease  among  milk  drinkers. 

12.  The  elimination  of  other  common  carriers  of  infection. 

13.  The  effect  upon  the  epidemic  of  closing  the  dairy  or  taking 
such  measures  as  will  eliminate  possibility  of  milk  contamination 
from  the  suspected  focus. 

14.  The  finding  of  the  specific  organism  in  the  milk. 

REFERENCES   ON    EPIDEMIOLOGY 

The  literature  of  epidemiology  is  voluminous  and  scattered  through 
a  great  variety  of  text-books  and  periodicals.  For  special  reference  to 
the  epidemiology  of  milk  see  "  Milk  and  Its  Relation  to  the  Public 
Health  "  (Bull.  56,  Hygienic  Laboratory,  U.  S.  Public  Health  Service, 
1909),  in  which  Trask  has  summarized  the  subject;  also  the  references 
on  milk  in  the  present  volume;  also  "The  Dissemination  of  Disease  by 
Dairy  Products,  and  Methods  of  Prevention,"  Circular  153,  Bureau  of 
Animal  Industry,  Department  of  Agriculture,  1910.  Whipple  has 
treated  the  subject  of  typhoid  fever  epidemiology  in  full  in  his  "  Typhoid 
Fever,"   1908.     The  Reports  on  "  Typhoid  Fever  in  the  District  of 

^  Trask,  loc.  cit. 


COMMUNTCATiLE   DISEASE  293 

Columbia"  (Bulletins  of  the  Hygienic  Laboratory,  Public  Ifealtli  Ser- 
vice) also  contain  a  large  amount  of  useful  information. 

GENERAL   REFERENCES  ON   COMMUNICABLE   DISEASE 

No  attempt  can  here  be  made  to  give  a  complete  list.  The  following, 
however,  may  be  mentioned  among  works  dealing  with  the  adminis- 
trative aspects  of  communicable  disease: 

Rosenau,  "  Preventive  Medicine  and  Hygiene,"  Appleton,  New  York, 
1913.  (A  comprehensive  treatise  which  has  been  used  as  the  authority 
for  many  of  the  statements  in  the  foregoing  chapter.) 

Chapin,  "  The  Sources  and  Modes  of  Infection,"  Wiley  and  Sons, 
Inc.,  New  York,  1912. 

Doty,  "  Prevention  of  Infectious  Disease,"  Appleton,  191 1. 

Kerr  and  Moll,  "  Communicable  Diseases:  An  Analysis  of  the  Laws 
and  Regulations  for  the  Control  thereof  in  force  in  the  United  States," 
Pub.  Health  Bull.,  no.  62,  U.  S.  Pub.  Health  Service,  July,  1913. 

Reports  of  the  Committee  of  the  American  Public  Health  Associa- 
tion on  the  Study  and  Prevention  of  Communicable  Diseases,  Am. 
Jour.  Pub.  Health,  1912  (vol.  II,  no.  2),  1913  (vol.  Ill,  no.  4),  1914 
(vol.  IV,  no.  3)  et  seq.;  and  of  special  committees  appointed  from  time 
to  time.  The  Mass.  Assn.  of  Boards  of  Health  has  a  committee  with 
similar  object  (report  in  Am.  Jour.  Pub.  Health,  1914,  vol.  IV,  no.  4, 

P-  334)- 

Various  papers  in  Transactions  of  the  XV  International  Congress 
on  Hygiene  and  Demography,  1912,  Government  Printing  Ofifice, 
Washington,  1913. 


?94 


A  MANUAL   FOR  HEALTH  OFFICERS 


TABLE 
Important  Data  Concerning  Some 


Causative 

Chief  modes  of 

Incubation 

Disease 

organism 

Infection  exists  in 

transmission 

period 

Diphtheria 

Bacillus  diph- 

Secretions    from 

Contact,     ingesta 

2  to  7  days, 

theria  (Klebs- 

nose  and  throat.' 

(especially  milk). 

oftenest  2. 

Loeffler) 

Scarlet  fever 

Unknown 

Secretions      from 
nose  and  throat' 
(apparently  not 
in      desquama- 
tion). 

ditto. 

I  to  7  days, 
oftenest  2 
to  4- 

Measles 

Unknown 

Secretions       from 
nose  and  throat 
(in     desquama- 
tion?). 

Contact. 

9  to  II  days, 
possibly 
14. 

Whooping 

Bacillus      per- 

Secretions      from 

ditto. 

7  to  14  days. 

cough 

tussis    (Bor- 
det-Gengou) 

nose  and  throat. 

Tuberculosis 

BgcHIus 

Sputum  (pulmon- 
ary  form),    dis- 

Contact,    ingesta 

tuberculosis 

(especially  milk). 

charges        from 

(dust). 

lesions       (other 

forms) . 

Typhoid 

Bacillus 

Excreta        (stools 

Contact,     ingesta 

8  to  23  days. 

fever 

typhosus- 

and  urine). 

(especially  water 
and  milk),  flies. 

oftenest  2 
weeks. 

Smallpox 

Unknown 

Probably  all   dis- 
charges and  se- 
cretions,       and 
desquamation. 

Contact. 

8  to  20  days, 
oftenest 
12. 

Acute  ante- 

Unknown 

Secretions       from 

Contact,  bite  of  the 

Unknown 

rior  polio- 

nose and  throat, 

stable-fly  {sio- 

myelitis 

also    apparently 

tnoxys  calcitrans). 

(Infantile 

in  blood. 

Other  modes  (?)< 

paralysis) 

Cerebrospinal 

Meningococcus^ 

Secretions      from 

Contact. 

Unknown. 

fever 

nose  and  throat. 

Rabies 

Unknown 

Nervous     system 
and  saliva  of  in- 
fected animal. 

Bite  of  rabid  ani- 
mal. 

See  text. 

»  And  discharges  from  lesions  in  other  parts,  such  as  ear,  etc. 

»  Termed  also  B.  typhi. 

8  Termed  also  Diplococcus  intracellularis  meningitidis  (Weichselbaum). 


COMMUNICABLE    DISKASK 


295 


III 

OF  THE  Chief  Communicable  Diseases 


How  long  infective ' 


Until  germs  disappear 
(two consecutive  neg- 
ative cultures  from 
nose  and  throat,  24 
hrs.  apart). 

Until  recovery,  includ- 
ing disappearance  of 
discharges.  Minimum 
4  weeks.  Dcsciuama- 
tion  no  indication. 

Until  complete  recov- 
ery. Minimum  10 
days  following  ap- 
pearance of  rash. 

Until  complete  recov- 
ery. 

Until  germs  disappear 
from  sputum  or  other 
discharge. 


Until  germs  disappear 
from  stools  and  urine 
(usually  during  con- 
valescence, 5  or  6 
weeks  after  onset). 


Until  recovery,  des- 
quamation and  heal- 
ing of  scars  complete. 

Until  some  time  after 
recovery  from  acute 
symptoms ,  exact  time 
not  known. 


Until  disappearance  of 
germs. 


Until  death  of  animal. 


Chief  restrictive  measures 


Applied  to  patient 


Isolation,  with  disinfection 
of  infectious  secretions. 
Immunization  of  contacts 
(antitoxin). 

Isolation,  with  disinfection 
of  infectious  secretions. 


Modified  isolation. 


ditto. 


Care  of  sputum.  If  neces- 
sary more  or  less  isolation. 
Furtherance  of  cure. 


Isolation,  with  disinfection 
of  stools  and  urine.  Anti- 
typhoid inoculation  of  ex- 
posed persons. 


Isolation,  with  disinfection 
of  discharges  and  secre- 
tions.'' Vaccination  of  con- 
tacts and  exposed  persons. 

Isolation,  with  disinfection 
of  secretions.  Screening 
against  flies.  Use  of  i  per 
cent  hydrogen  peroxide 
gargles,  sprays,  and  nose 
washes  by  patient,  nurse, 
physician,  and  other  ex- 
posed persons. 
Treatment  of  patient  with 
anti-meningitis  serum. 
Isolation,  with  disinfec- 
tion of  secretions.  Use  of 
antiseptic  gargles  and  nasal 
douches  and  immuniza- 
tion by  killed  cultures,  for 
exposed  persons. 

Pasteur  treatment. 


Applied  to  community 


Lessening  of  opportunities  for  con- 
tact infection  from  carriers,  in- 
cipient cases,  and  missed  cases. 
Protection  of  food  supplies  (pas- 
teurization of  milk,  etc.). 
ditto. 


Lessening  of  opportunities  for  con- 
tact   infection    (incipient   and 
missed  cases,  etc.).     Early  dis- 
covery and  reporting  of  cases. 
ditto. 


Attention  to  housing,  factory 
hygiene,  modes  of  living,  etc. 
Lessening  of  opportunities  for 
contact  infection.  Tuberculin- 
testing  of  dairy  cattle,  or  pas- 
teurization of  milk.  Protection 
of  food  supplies  from  infection. 

Lessening  of  opportunities  for 
contact  infection  (carriers, 
etc.).  Protection  of  food  and 
water  supplies  (pasteurization 
of  milk).  Anti-typhoid  inoc- 
ulation under  special  condi- 
tions of  exposure. 

Vaccination. 


Lessening  of  opportunities  for 
contact  infection  (carriers, 
etc.).  Reduction  of  stable 
flies.  Use  of  antiseptic  gar- 
gles, sprays,  etc.,  in  epidemics. 


Lessening  of  opportunities  for 
contact  infection  (carriers, 
etc.).  Use  of  antiseptic  gar- 
gles, sprays,  etc.,  in  epidemics. 


Regulation  of  keeping  of  dogs 
and  destruction  of  ownerless 
dogs. 


*  Transmission  imperfectly  understood. 

'  Opinion  varies.     Cf.  discussions  in  text ;  also  periods  given  on  p.  633. 

6  Carbolic  acid  and  coal-tars  probably  not  effective  in  disinfection. 


CHAPTER    II 
CHILD   HYGIENE 

A  progressive  department  of  health  cannot  long  overlook  the  neces- 
sity for  work  directed  toward  the  conservation  of  child  life.  When  it  is 
considered  that  approximately  one-fourth  of  the  total  mortality  in 
municipalities  is  made  up  of  the  mortality  in  children  under  five  years 
of  age,  the  importance  of  work  along  these  lines  can  scarcely  be  over- 
estimated, and  a  Bureau  of  Child  Hygiene  is  a  necessary  adjunct  to  a 
well-organized  Health  Department.^ 

The  term  "child  hygiene"  is  applied  in  a  general  way  to 
all  public  health  work  having  for  its  purpose  the  protection 
of  children  from  birth  up  through  school  age.  Its  most 
important  division  is  that  of  infant  hygiene,  which  applies 
chiefly  to  the  care  of  infants  under  two  years  of  age,  and 
to  which  special  attention  will  be  devoted  in  the  present 
chapter. 

MEDICAL  INSPECTION   AND    SANITATION    OF 
SCHOOLS 

Medical  inspection  of  school  children,  as  already  remarked 
in  Chapter  I,  has  two  objects:  (i)  the  general  physical 
welfare  of  each  child;  and  (2)  the  detection  and  exclusion 
of  communicable  disease  from  the  schools.  The  latter 
division  of  the  subject  was  discussed  in  that  chapter,  leav- 
ing the  former  division,  which  consumes  the  greater  labor 
and  expense,  to  be  considered  in  the  following  general  dis- 
cussion of  the  whole  matter. 

The  importance  of  school  hygiene  in  the  broadest  sense, 
including  medical  inspection,  upon  the  health  and  develop- 

'  Rpt.  of  Committee  on  Organization  and  Functions  of  Municipal 
Health  Departments,  of  the  American  Public  Health  Association,  1912. 

296 


CHILD   HYGIENE  297 

ment  of  the  child  all  during  the  school-going  age,  requires 
no  amplification  here.  As  to  medical  inspection,  (Mther  of 
the  objects  above-mentioned  is  a  sufficient  reason  for  its 
institution. 

Leaving,  then,  the  subject  of  detection  of  communicable 
disease  as  having  been  outlined  under  that  head,  we  con- 
sider here  more  especially  the  function  of  medical  inspec- 
tion in  securing  the  general  physical  welfare  of  the  school 
child.  This  consists,  briefly,  in  detecting  physical  defects 
and  non-communicable  diseases  in  the  child  and  seeing 
that  these  are  remedied.  Defects  of  nose,  throat,  eyes, 
teeth,  ears  and  other  physical  deficiencies  and  handicaps 
are  the  subjects  of  medical  inspection,  which  by  detecting 
them  and  causing  their  removal  confers  great  present  and 
future  benefits  upon  the  growing  child,  to  whom,  frequently, 
little  attention  in  these  respects  is  paid  by  parents. 

For  adequate  medical  inspection  both  doctors  and 
nurses  are  necessary.  The  school  nurse  plays  an  indis- 
pensable part,  not  only  in  assisting  the  medical  inspector 
in  his  examinations,  but  also  in  following  up  cases  and 
seeing  that  they  receive  the  necessary  home  and  medical 
treatment  and  (if  the  child  has  been  excluded)  are  returned 
to  school  at  the  earliest  possible  time. 

Control  of  Medical  Inspection.  —  There  is  frequently  a 
question  as  to  the  control  of  medical  inspection:  should  it 
be  under  the  health  or  under  the  school  authorities?  The 
laws  on  the  subject  vary.  There  are  advantages  in  having 
everything  within  the  school  walls  under  the  control  of 
the  school  authorities.  On  the  other  hand,  if  there  is 
medical  inspection  of  parochial  and  private  schools,  it 
must  be  managed  by  the  health  department  and  it  may 
then  be  best  to  have  the  whole  system,  including  public 
school  inspection,  under  its  control.  Local  circumstances 
and  laws  must  decide  the  question.  Where  medical  in- 
spection includes,  as  it  should,  inspection  for  physical  de- 
fects as  well  as  for  communicable  disease,  it  is  frequently 


298  A  MANUAL  F(jR  HEALTH  OFFICERS 

under  the  control  of  the  'educational  authorities,  although 
it  may  properly  be  initiated  and  controlled  by  the  health 
authorities  where  they  are  progressive  and  local  circum- 
stances place  the  responsibility  upon  them.^  Control  by 
the  health  authorities  is  recommended  by  the  special  com- 
mittee of  the  American  Public  Health  Association  (recom- 
mendations below). 

Recommendations  of  the  Committee  of  the  American 
Public  Health  Association  on  Medical  Inspection  of 
Schools  and  School  Children. ^ 

First,  that  a  system  of  medical  inspection  of  schools  be  established 
in  every  city. 

Second,  that  the  control  of  the  same  be  under  the  board  of  health. 

Third,  that  the  work  include  the  exclusion  of  cases  of  contagious 
diseases  and  the  recommendation  of  the  correction  of  physical  defects. 

Fourth,  that  dental  inspection  be  part  of  the  system  and  that  the 
inspection  be  made  by  dentists  in  the  employ  of  the  board  of  health, 
and  that  a  free  dental  clinic  or  clinics  under  the  control  of  the  board  of 
health  be  established  for  the  care  of  children  unable  to  pay. 

Fifth,  that  all  physical  examinations  except  those  for  defective  teeth 
be  made  by  physicians  and  not  by  teachers  or  nurses,  and  that  dental 
examinations  be  made  by  dentists. 

Sixth,  that  the  maximum  number  of  pupils  under  supervision  of 
one  doctor  and  one  nurse  be  3000,  and  that  the  number  be  reduced  as 
much  as  possible.  It  would  be  better  to  have  one  nurse  for  each  1500 
pupils. 

Seventh,  that  clinics  be  established  under  the  control  of  boards  of 
health  for  the  purpose  of  correcting  the  physical  defects  found  in  school 
children. 

Eighth,  that  nurses  be  reriuired  to  devote  their  whole  time  to  this 
work  and  be  paid  a  salary  of  not  less  than  $900  a  year  and  that  doctors 
be  required  to  devote  only  part  of  their  time  but  not  less  than  two  hours 
per  day  to  the  work  and  be  paid  a  salary  ranging  from  $600  to  $900  per 
year. 

The  foregoing  discussion  merely  outlines  the  subject  of 

'  See  discussion  of  the  question  by  Gulick  and  Ayres  in  their  book 
cited  under  references. 

2  Am.  Jour.  Pub.  Health,  1913,  vol.  Ill,  no.  4,  p.  391. 


CIKI.I)    nVflfllNK  299 

medical  inspection  of  schools.      For  flctailcd   iiifonn.ition 
the  reader  is  referred  to  the  references  below. 

The  hygiene  and  sanitation  of  school  buildings  is  an  im- 
portant subject  of  supervision,  the  responsibility  for  which 
rests  partly  with  health  authorities,  partly  with  educa- 
tional authorities.  Sanitary  control  should  be  exercised 
over  school  water  supplies  and  privies  (in  rural  districts), 
cleanliness  and  ventilation,  while  common  drinking  cups 
and  the  like  should  be  barred  (see  Chapters  I,  IV,  V, 
and  VI). 

School  instruction  in  hygiene  is  a  function  of  the  edu- 
cational authorities.  It  would  be  well,  however,  for  the 
latter  in  many  cases  to  consult  the  health  officer  as  to 
the  efTectiveness  of  the  text-book  used.  Such  books,  in 
the  higher  grades,  may  include  not  only  sound  instruction 
in  personal  hygiene  but  also  a  simple,  non-technical  sketch 
of  municipal  sanitation. 

Open-air  Schools.  —  There  are  two  classes  of  school- 
children whose  health  requires  special  attention:  (i)  those 
affected  with  latent  tuberculosis;  and  (2)  those  who  are 
simply  anaemic,  underdeveloped,  run-down,  etc.  Open-air 
schools  and  special  regimes  should  be  provided  for  these 
two  classes,  separate  and  distinct  from  each  other,  although 
the  treatment  in  the  two  cases  does  not  differ  materially. 
The  maintenance  of  such  schools,  or  classes,  may  be  said 
to  constitute  a  branch  of  school  hygiene  which  cannot  be 
treated  in  detail  here."^ 

1  See  Gulick,  "  Tuberculosis  and  the  Public  Schools  "  (reprint  of 
Dept.  of  Child  Helping,  Sage  Foundation,  130  East  22nd  St.,  N.  Y.  City); 
Cabot,  "Tuberculosis  Among  School  Children,"  Trans.  XV  InUrnat. 
Congress  Hyg.  ajid  De^nogr.,  1912,  vol.  Ill,  pt.  I;  Warren,  "Open- 
air  Schools  for  the  Prevention  and  Cure  of  Tuberculosis  Among  Chil- 
dren," Pub.  Health  Bull.,  no.  58,  U.  S   Pub.  Health  Service,  1912. 


300  A  MANUAL  FOR  HEALTH  OFFICERS 

REFERENCES 

Gulick  and  Ayres,  "  Medical  Inspection  of  Schools,"  Charities  Pub- 
lication Committee,  105  East  22nd  St.,  N.  Y.  City,  1913. 

Cornell,  "  Health  and  Medical  Inspection  of  School  Children,"  1912. 

Newmayer,  "  Medical  and  Sanitary  Inspection  of  Schools,"  1913. 

Rapeer,  "  School  Health  Administration,"  1913. 

Hogarth,  "  Medical  Inspection  of  Schools,"  London,  1909. 

Stevens,  "  Medical  Supervision  in  Schools,"  London,  1910. 

Ayres,  "  Open-Air  Schools." 

Putnam,  "  School  Janitors,  Mothers,  and  Health,"  Am.  Acad. 
Medicine  Press,  1913. 

Allen,  "  Civics  and  Health." 

Proceedings  of  the  International  Congresses  on  School  Hygiene 
(Secretary,  Dr.  T.  A.  Storey,  College  of  the  City  of  New  York). 

Among  school  hygienes  may  be  mentioned  the  Gulick  Hygiene  Series 
(Ginn  and  Co.). 

INFANT  HYGIENE 

INFANT  MORTALITY:    THE  PROBLEM 

Infant  mortality  is  one  of  the  great  public  health  prob- 
lems of  today.  Until  recently  it  was  imperfectly  under- 
stood, attacked  only  piecemeal,  organized  efforts  being 
largely  those  of  private  philanthropy;  but  such  an  attitude 
on  the  part  of  health  authorities  can  no  longer  be  justified. 
It  must  now  be  attacked  by  the  health  authorities  in  close 
cooperation  with  the  other  social  agencies  involved.  Sir 
Arthur  Newsholme,  the  great  English  statistician,  has  said: 

Infant  mortality  is  the  most  sensitive  index  we  possess  of  social 
welfare.  If  babies  were  well  born  and  well  cared  for,  their  mortality 
would  be  negligible.  The  infant  death  rate  measures  the  intelligence, 
health  and  right  living  of  fathers  and  mothers,  the  standards  of  morals 
and  sanitation  of  communities  and  governments,  the  efficiency  of  physi- 
cians, nurses,  health  officers,  and  educators. 

While  there  is  here  much  that  cannot  be  dealt  with  by 
health  authorities  alone,  it  is  evident  that  they  have  im- 
portant duties  to  perform,  and  that  the  main  aspects  of  the 
infant  hygiene  problem  must  now  be  regarded  as  subjects, 
not  of  philanthropy,  but  of  public  health  administration. 


cniij)  iiY(;n;Ni'; 


301 


The  basic  statistics  of  infant  iiujrtality  arc  set  forth  in 
Tables  IV  and  V  and  Ciiart  4.  The  large  percentage  of 
deaths  under  one  year  of  age  is  evident  and  suggests  the 

Chart  4.    The  Problem  of  Infant  Mortality. 
U.  S.  Rcs?istration  Area,  191 1.       (Based  on  Tables  IV  and  V.) 
Shaded  Portion  represents  fifty  per  cent  (or  more)  preventable. 


DEATHS  BY  AGE 


DEATHS   UNDER  ONE  YEAR 
BY  CAUSE 


inquiry  into  the  causes  of  death  which  is  made  in  Table  V 
and  the  second  diagram  in  the  chart. 


TABLE  IV 

Mortality  by  Age 

Registration  Area  of  the  United  States.     (From  U.  S.  Mortality 
Statistics  for  191 1,  Bureau  of  the  Census.)     Stillbirths  not  included. 


Age  group 

Number  of  deaths 

Per  cent  of  total 

All  ages 

839.284 

149,322 

60,160 

209,482 

100  0 

Under  i  year 

17.8 

7.2 

25.0 

I  to  5  years 

Total  under  5  years 

Specific  Causes.  —  The  causes  may  be  commented  upon 
in  a  general  way  as  follows : 


302 


A  MANUAL   FOR   HEALTH  OFFICERS 


TABLE   V 

Causes  of  Infant  Mortality 

(Deaths  under  one  year.) 

Registration  Area  of  the  United  States.     (From  U.  S.  Mortality 

Statistics  for  191 1,  Bureau  of  the  Census.)     Stillbirths  not  included. 


Nos.  (In- 
ternational 
classifi- 
cation) 


104 
86-9S 


6-10 

28-35 
37 


150,151 


Causes  and  numbers  of  deaths 


All  causes 149,322 

Diarrhoea  and  enteritis 37,579 

Diseases  of  the  respiratory  system  : 
89.    Acute  bronchitis 3,589 

91.  Bronchopneumonia....    10,652 

92.  Pneumonia  (lobar  2465, 

undefined  4846) 7,311 

Other  diseases  of  respir- 
atory system 1,077 

Total 22,629 

Chief  communicable  diseases  : 

6.  Measles 1,319 

7.  vScarlet  fever 243 

8.  Whooping  cough 3,687 

9.  Diphtheria  (and  croup)  887 

10.  Influenza 660 

28.  Tuberculosis  of  lungs...  865 

30.  Tuberculous  meningitis  1,166 

31.  Abdominal  tuberculosis  225 
Other   forms   of    tuber- 
culosis   344 

(28-35  Total  tuberculosis  2600) 

37.    Syphilis 1,787 

Total 11,183 

Congenital  malformation  and  de- 
bility: 

150.  Congenital  malformation 

(stillbirths  not  included)     7,879 

151.  Congenital  debility,  ic- 

terus and  sclerema.  . .  38,434 

Total 46,313 

All  other  causes 31,618 


Per  cent 
of  all 
causes 


100. 0 
25.2 


IS-2 


7-5 


311 
21 .0 


Diarrhcea  and  Enteritis  (25.2  per  cent).  —  Due  to  improper 
methods  of  feeding,  —  especially  to  the  substitution  of 
artificial  for  breast  feeding,  —  to  bad  milk  supplies,  and 


CHILD  HYGIENE  303 

also,  to  some  extent,  to  improper  clothing,  irregular  hours 
of  sleep  and  other  improper  conditions  leading  to  digestive 
disturbances.  A  great  increase  in  this  cause  of  death  comes 
with  the  heated  season,  during  which  the  alimentary  system 
of  infants  becomes  debilitated  and  milk  supplies  tend  to 
suffer  deterioration.  Much  gastrointestinal  disease  is  bac- 
terial in  cause  and  the  infection  is  favored  by  the  warmth 
and  flies^  of  summer  time,  as  well  as  by  filth  and  contact. 
As  to  artificial  feeding,  it  is  estimated  that  bottle-fed  babies 
have  only  one-tenth  the  chance  to  live  that  breast-fed  babies 
have.2  Through  the  application  of  known  hygienic  prin- 
ciples practically  all  the  deaths  from  diarrhoea  and  enteritis 
could  be  saved.  It  has  been  suggested  that  infantile 
diarrhoea  be  added  to  the  list  of  reportable  diseases,  so 
that  its  distribution  and  causes  may  be  studied  and  where 
necessary  the  cases  be  visited  by  the  infant  hygiene  nurse. 

Diseases  of  the  Respiratory  System  (15.2  per  cent).  —  This 
group  of  deaths  is  due  to  improper  care  on  the  part  of 
mother  or  nurse  as  to  ventilation,  clothing  and  the  like  — 
all  preventable.  A  number  of  these  deaths  is  doubtless  also 
due  to  the  sequelae  of  whooping  cough,  measles  and  other 
communicable  diseases,  the  latter  being  omitted  from 
mention  in  the  death  certificate. 

Communicable  Diseases  (7.5  per  cent).  —  It  is  not  com- 
monly realized  how  large  a  toll  is  exacted  by  the  so-called 
minor  preventable  diseases  of  childhood  —  chiefly  measles 
and  whooping  cough  —  which  act  mainly  through  their 
disastrous  aftereffects.  Protection  from  infection  would 
obviate  infection  from  these  as  well  as  from  scarlet  fever, 
diphtheria  and  influenza.      Under   this  head  is  included 

1  A  recent  investigation  made  by  Dr.  Donald  B.  Armstrong  for  the 

New  York  Association  for  Improving  the  Condition  of  the  Poor  ("  Flies 
and  Diarrhoeal  Disease,"  Publication  no.  79),  while  based  upon  imper- 
fect experimental  conditions,  suggests  an  important  relationship  be- 
tween the  prevalence  of  flies  and  the  occurrence  of  diarrhceal  disease 
among  infants. 

^  U.  S.  Children's  Bureau,  "  Baby-saving  Campaigns,"  1913,  p.  45. 


304  A  MANUAL  FOR   HEALTH  OFFICERS 

also  tuberculosis.  About  one-quarter  to  one-half  of  all 
cases  of  tuberculosis  in  children  under  five  years  of  age  is 
associated  with  the  bovine  type,  and  it  is  probable  that  all 
these  cases  derive  their  infection  through  the  tubercle 
bacilli  in  cow's  milk  (Rosenau).  Much  of  the  tuberculosis 
in  infants  is  therefore  preventable  through  the  safeguarding 
of  milk  supplies  and  the  remainder  through  prevention  of 
direct  infection  from  tuberculosis  mothers  and  other  mem- 
bers of  the  family.  The  prevention  of  the  syphilis  which 
contributes  also  to  this  head  is  a  more  difficult  problem, 
depending  as  it  does  upon  the  whole  control  of  venereal 
disease.  On  the  whole  we  may  say  that  the  group  of  com- 
municable diseases  is  almost  entirely  preventable. 

Congenital  Malformation  and  Debility  (31.1  per  cent). — 
Many  of  the  deaths  in  this  group  are  due  to  inherited  con- 
ditions not  susceptible  of  control  through  public  hygiene. 
Many  of  them,  however,  might  be  saved  through  prenatal 
precautions  on  the  part  of  the  mother,  while  others  would 
live  if  proper  care  were  taken  of  the  infant  after  birth. 
Others  are  due  to  venereal  disease  of  parents.  It  may  be 
reasonably  considered  that  a  certain  proportion  of  this 
group  is  preventable  through  hygienic  measures,  prenatal 
and  postnatal. 

The  group  of  all  other  causes  (21.0  per  cent)  is  not  sus- 
ceptible of  much  analysis,  although  here  also  there  are 
doubtless  a  small  number  of  preventable  deaths. 

Summing  up,  it  may  be  stated  that  of  these  deaths  under 
one  year  (of  which  the  Census  Bureau  estimates  that  the 
loss  in  1912  was  about  300,000)  "at  least  half  would  now  be 
living  had  we,  as  individuals  and  communities,  applied 
those  measures  of  hygiene  and  sanitation  which  are  known 
and  available."  Such  is  the  statement  of  the  Chief  of 
the  National  Children's  Bureau  (italics  by  the  present 
author),  who  continues: 

Here  is  a  vast  and  unmeasured  loss  of  infant  life  due  solely  to  individ- 
ual and  civic  neglect.     The  economic  and  industrial  significance  of  such 


cm  1. 1)    IIYOIKNK  305 

a  loss  in  the  general  scheme  of  social  well-hcin^j  is  beginning  to  be 
realized.  It  was  once  thought  that  a  high  infant  death  rate  indicated 
a  greater  degree  of  vigor  in  the  survivors.  It  is  now  agreed  that  the 
conditions  which  destroy  so  many  of  the  youngest  lives  of  the  com- 
munity must  also  result  in  cri[)pling  and  maiming  many  others  and  must 
react  unfavorably  upon  the  health  of  the  entire  community.' 

Infant  Mortality  Rates.  —  The  "  infant  mortality  rate," 
in  the  proper  use  of  the  term,  is  "the  ratio  of  deaths  under 
one  year  of  age  to  births"  (cf.  page  516).  The  ratio  is 
always  calculated  on  this  basis  for  the  reason  that  the  esti- 
mated population  under  one  year  of  age  is  subject  to  inac- 
curacy. The  calculation  of  an  accurate  infant  mortality 
rate  therefore  depends  upon  a  practically  complete  regis- 
tration of  births,  a  condition  which  as  yet  exists  in  few 
places  in  this  country.  Even  among  the  Census  Bureau 
figures  only  a  small  percentage  of  the  returns  are  as  yet 
at  all  satisfactory.  These  may  be  taken,  however,  to 
indicate  that  for  1910  the  infant  mortality  rates  for  the 
most  reliable  cities  of  100,000  population  or  over  ranged 
from  82  to  231  per  thousand  births.^  The  former  of 
these  rates  occurred  in  a  comparatively  new  western  city, 
while  the  latter  occurred  in  one  of  the  older  eastern  cities 
with  some  congestion  and  a  factory -working  population. 
Of  course  the  ultimate  goal  to  be  aimed  at  is  much  below 
any  of  these  rates,  especially  as  where  birth  registration 
is  deficient  the  calculated  rate  appears  higher  than  it 
actually  should  be. 

In  the  second  year  of  life  the  death  rate  is  considerably 
lower  (see  Chart  i,  page  74).  There  is  a  decrease  in 
diarrhoeal  and  respiratory  diseases  and  in  congenital  mal- 
formation and  debility;  the  communicable  diseases,  how- 
ever, keep  up  to  the  same  numbers  as  the  first  year, 
indicating  that  while  vital   resistance  is  greater  the  sus- 

^  isi  Ann.  Rpt.  of  the  Chief,  Children's  Bureau,  to  the  Secretary 
of  Labor,  for  year  ending  June  30,  1913,  p.  7. 
*  Mortality  Statistics  for  191 1. 


3o6  A  MANUAL   FOR   HEALTH  OFFICERS 

ceptibility  (and  exposure)  to  infection  remains  the  same 
(Registration  Area  statistics  for  19 lo). 

Causes  of  Death  by  Age.  —  A  table  giving  the  deaths 
of  infants  by  cause,  as  follows,  by  days  for  the  first  week, 
by  weeks  for  the  first  month,  by  months  for  the  first  year 
and  by  years  for  the  first  five  years  of  life  is  very  instructive. 
Such  a  table  shows  that  among  the  very  earliest  deaths 
congenital  defects  and  injuries  at  birth  form  a  majority. 

Of  the  deaths  occurring  in  the  early  days  of  life,  a  large  proportion  are 
the  result  of  conditions  existing  before  birth.  The  latest  reports  of  the 
Bureau  of  the  Census  on  mortality  statistics  show  that  slightly  more 
than  42  per  cent  of  the  infants  dying  under  one  year  of  age  in  the  regis- 
tration area  in  191 1  did  not  live  to  complete  the  first  month  of  life,  and 
that  of  this  42  per  cent  almost  seven-tenths  died  as  a  result  of  prenatal 
conditions  or  of  injury  and  accident  at  birth.  Of  those  that  lived  less 
than  one  week  about  83  per  cent  died  of  such  causes,  and  of  the  num- 
ber that  lived  less  than  one  day  94  per  cent  died  of  these  causes.^ 

These  facts  constitute  the  reason  for  prenatal  work  and 
for  the  control  of  midwifery  and  the  raising  of  standards 
of  obstetrics  and  obstetrical  nursing. 

After  the  first  month  this  class  of  causes  rapidly  declines, 
and  the  causes  due  to  external  conditions  in  the  care  of  the 
infant  loom  large.  Hence  the  reason  for  postnatal  work 
touching  the  care  of  the  infant,  milk  supplies  (where  arti- 
ficial feeding  is  resorted  to  and  when  the  child  is  being 
weaned),  etc. 

Communicable  disease  keeps  up  a  steady  incidence  at  all 
ages,  hence  the  child  must  be  continually  protected  from 
the  so-called  "minor"  (but  in  reality  dangerous)  diseases 
measles,  whooping  cough  and  influenza,  as  well  as  from 
scarlet  fever  and  diphtheria. 

Underlying  Conditions  and  Problems.  —  We  have  now 
passed  in  review  in  some  detail  the  specific  causes  of  infant 
mortality  and  may  now  consider  the  general  conditions 
which  favor  it.     The  chief  of  these  are  ignorance  and  pov- 

*  1st  Ann.  Rpt.,  Chief  of  Children's  Bureau,  1913,  p.  ii. 


CHILD   HYGIENE  307 

erly.  Then  comes  milk  supply,  once  thought  to  play  the 
very  first  part  in  the  situation  but  now  recognized  to  be 
secondary,  though  still  important.  Finally,  there  are  the 
effects  of  bad  midwifery  and  obstetrics,  bad  housing,  dirt 
and  congestion,  flies,  factory-working  of  mothers  recent  or 
prospective,  occasionally  neglect,  and  other  related  condi- 
tions. All  of  these  conditions,  with  the  exception  of 
poverty,  may  be  attacked  by  the  public  health  authorities, 
while  even  the  effects  of  poverty  may  be  combatted  through 
the  assistance  of  charitable  and  social  agencies. 

A  brief  consideration  of  the  history  of  efforts  against 
infant  mortality  is  instructive.  It  was  once  thought  that 
by  removing  ailing  babies  from  tenements  and  placing  them 
in  asylums  and  hospitals  they  would  be  saved,  until  it  was 
found  by  experience  that  the  institutions  had  high  death 
rates  and  did  not  accomplish  at  all  the  benefits  expected 
from  them  and  that  the  child  should  be  kept  whenever 
possible  with  the  mother.  The  reliance  upon  improved 
milk  supplies  entirely  to  save  the  situation  was  also  dis- 
appointed. While  the  pure  milk  movement  has  had  a 
strong  effect  in  the  promotion  of  infant  and  child  hygiene, 
its  limitations  have  now  been  recognized.  The  best  grades 
of  milk,  such  as  certified  milk,  are  out  of  reach  of  the  pocket 
books  of  many,  and  the  facilitation  of  the  distribution  of 
superior  milk,  where  arranged,  has  frequently  (though  not 
invariably)  tended  to  discourage  the  greatest  salvation  of 
the  infant  —  maternal  nursing. 

TRE  REDUCTION  OF  INFANT  MORTALITY 

The  following  means  of  reduction  should  be  undertaken 
by  municipal  health  authorities,  except  in  so  far  as  such 
activities  are  carried  on  by  private  organizations. 

I.  A  General  Survey  of  the  situation  should  be  made. 
This  will  involve  a  study  of  the  statistics  of  infant  mor- 
tality and  a  consideration  of  the  available  means  for  meet- 
ing the  situation  disclosed.     All  deaths  of  infants  under 


3o8  A  MANUAL   FOR  HEALTH   OFFICERS 

two  years  of  age  should  be  tabulated  and  studied  for  two 
or  more  years  back.  They  should  be  plotted  on  a  spot  map 
so  as  to  bring  out  their  topographical  distribution  and  thus 
indicate  the  particular  districts  in  which  work  is  most 
needed.  They  should  also  be  studied  by  age  and  by  causes, 
by  color  and  nationality  of  parents,  etc.,  so  that  the  health 
officer  may  have  a  thorough  familiarity  with  the  problem 
to  be  attacked.  Later  on,  after  work  is  organized,  inten- 
sive studies  of  selected  districts,  pertaining  to  morbidity  as 
well  as  mortality,  should  be  made,  so  that  further  knowl- 
edge of  underlying  causes  may  be  gained.  As  already 
emphasized,  accurate  infant  mortality  figures  require  as  a 
basis  not  only  good  death  records  but  also 

2.  Complete  and  Accurate  Registration  of  Births.  — 
This  is  a  first  and  indispensable  requirement  which  will  be 
discussed  in  Chapter  IX.  It  is,  moreover,  the  starting 
point  of  instructive  nursing  and  other  preventive  measures. 

3.  Home  Instruction.  —  The  chief  cause  of  infant  mor- 
tality being  unhygienic  care  of  the  infant  on  the  part 
of  mother  or  nurse,  grounded  in  ignorance  frequently 
rendered  hidebound  by  prejudice,  the  strongest  step  that 
can  be  taken  is  the  instruction  of  mothers.  One  chief  way 
of  accomplishing  this  is  through  home  instruction  by  an 
infant  hygiene  nurse.  Such  instruction  is  either  prenatal 
—  before  the  birth  of  the  child  —  or  postnatal.  We  shall 
refer  again  below  to  prenatal  work,  dwelling  here  especially 
on  the  postnatal  instruction  in  the  hygiene  of  the  infant. 

Here  again  a  prompt  and  full  notification  of  births  is 
of  prime  importance.  Without  such  notification  valuable 
time  is  lost  and  the  cases  needing  attention  cannot  be 
located.  From  the  birth  records  the  nurse  makes  a 
selection  of  cases  to  be  visited.  Many  of  the  cases  are 
in  hospitals  or  under  the  close  care  of  physicians,  nurses  or 
intelligent  families,  and  may  be  omitted,  while,  on  the  other 
hand,  it  may  be  wise,  if  the  work  is  limited  (as  is  fre- 
quently the  case,  at  least  at  the  outset),  to  select  only  the 


CHILD   HYGIENE  309 

midwife  cases  or  the  cases  in  certain  districts  where  the 
spot  map  of  mortality  shows  the  j^reatest  need.  The  medi- 
cal fraternity  should  understand  that  cases  may  he  re- 
ferred by  any  physician  with  any  instructions  which  he 
may  wish  to  have  explained  to  the  mother. 

The  following  arc  the  chief  points  to  which  attention  is 
paid  by  the  nurse: 

Feeding.  —  Advice  is  given  on  the  details  of  feeding 
and  physician's  instructions,  if  any,  are  followed  out. 
Breast-feeding  is  urged.  All  authorities  agree  that  this  is 
the  greatest  consideration  in  infant  hygiene.  The  effect 
of  artificial  feeding  is  greatly  to  increase  the  incidence  of 
diarrhoea,  enteritis  and  malnutrition,  and  to  render  more 
susceptible  to  other  affections. 

The  importance  of  maternal  nursing  cannot  be  overestimated. 
Were  mothers  able  universally  to  nurse  their  children,  one-third  to  one- 
half  of  infant  deaths  would  be  expunged  from  our  mortality  returns.^ 

Davis,  after  a  statistical  study  of  infant  deaths  in  Bos- 
ton, arrives  at  this  conclusion: 

Breast-feeding  of  all  babies  would  have  saved  nearly  a  thousand  lives 
last  year  [191 1,  in  Boston],  and  the  death  rate  per  1000  births  would 
have  been  71  instead  of  127.2 

There  are  various  reasons  for  the  failure  of  mothers  to 
nurse  their  infants:  among  them  alcoholism,  debility, 
industrial  employment,  disinclination  and  false  ideas. 
These  must  be  opposed  by  persuasion  and  education;  by 
aiding  the  mother  to  obtain  an  adequate  supply  of  breast 
milk  through  proper  diet  and  by  addition  to  her  diet  milk 
and  other  foods  having  this  effect;  by  remedying  so  far  as 
possible  the  factory  working  of  mothers  soon  after  confine- 
ment.    As  for  the  physiological  inability  to  nurse,  it  occurs 

1  Schereschewsky,  in  Bull.  56  of  the  Hyg.  Lab.,  Pub.  Health  Service. 

*  "  Prevention  of  Infant  Mortality  by  Breast-Feeding,"  Am.  Jour. 
Pub.  Health,  1912,  vol.  H,  no.  2,  p.  67;  also  "  Statistical  Comparison 
of  the  Mortality  of  Breast-fed  and  Bottle-fed  Infants,"  Trans.  XV 
Internal.  Congress  Hyg.  and  Dem.,  vol.  VI,  p.  188. 


3IO  A  MANUAL   FOR   HEALTH  OFFICERS 

very  seldom.  Figures  given  by  Dr.  Herman  Schwarz, 
director  of  the  Pediatric  Department  of  Dr.  Hill's  Mater- 
nity Clinic,  New  York,  show  that  of  1500  mothers  he  found 
only  four  who  could  not  nurse,  when  encouraged  by  proper 
care  and  advice  at  and  after  the  confinement.  Of  these 
1500  mothers  96.9  per  cent  nursed  i  month,  89.1  per  cent 
3  months  and  77  per  cent  6  months.^ 

The  proper  time  for  weaning  must  be  governed ;  in  some 
cases  the  tendency  is  to  wean  too  soon,  in  others  too  late. 

When,  in  the  opinion  of  the  medical  adviser,  the  feeding 
is  to  be  mixed  (as  in  natural  and  gradual  weaning)  or  the 
baby  is  to  be  put  entirely  on  the  bottle,  then  attention 
should,  so  far  as  deemed  advisable,  be  paid  to:  (i)  choice 
of  milk  supply,  (2)  home  modification,  (3)  home  pasteur- 
ization and  (4)  home  care  of  milk. 

(i)  The  milk  supply  must  be  obtained  from  a  milk  sta- 
tion or  other  special  source  or  from  a  market  source  ap- 
proved by  the  health  authorities. 

(2)  Home  modification.  It  appears  to  be  the  consensus 
of  opinion  of  those  who  have  given  attention  to  the  matter 
that  home  modification  of  milk  according  to  simple  formulas 
can  be  successfully  taught  to  nearly  all  mothers.  The  New 
York  Milk  Committee,  as  the  result  of  its  studies,  con- 
cluded "  that  home  modification,  even  among  the  very 
poor  and  ignorant,  is  possible,"  and  "that  the  results,  as 
shown  by  the  mortality  and  by  the  condition  of  the  sur- 
viving babies  at  the  end  of  the  period  of  demonstration, 
prove  that  as  good  results  can  be  obtained  as  when 
already  modified  milk  is  distributed."-  The  following  is 
the  experience  of  Newark,  N.  J.: 

All  milk  was  modified  at  the  home  by  the  mothers  themselves. 
There  is  no  difficulty  where  the  method  is  simple,  the  instructions  defi- 
nite, a  clean  milk  to  hand  and  the  cases  followed  by  doctor  and  nurse 

'  Figures  quoted  by  Public  Welfare  Committee  of  Essex  County, 
N.  J.,  which  obtained  similar  results  (Rpt.  already  cited). 
=  Op.  ciL,  p.  83. 


CiriLF)    MYfJIIONK  31  r 

that  speak  the  language  of  the  mother.  With  the  exception  of  a  very 
few  cases  we  required  nothing  but  raw  diluted  whole  milk,  cane  sugar, 
barley  water  and  salt.  This  I  would  emphasize  as  the  most  impressive 
and  important  phase  of  our  work,  because  in  this  way  alone  .  .  .  can 
rational,  intelligent  milk  modification  come  into  general  household  and 
general  professional  knowledge,  can  mothers  and  floctf)rs  learn  the  cost 
of  clean  milk,  its  value  and  where  to  obtain  it.  The  mothers  obtain  a 
working  knowledge  of  an  infant's  capacity  and  digestion,  and  when 
they  act  without  advice  they  will  at  least  have  some  experience  to  guide 
them.  In  this  work  of  home  modification  the  emphasis  is  laid  on  clean 
milk,  clean  bottles  and  nipples,  proper  intervals,  the  avoidance  of  addi- 
tional food,  and  not  on  the  modification.  Doctors  and  mothers  must 
be  weaned  from  the  superstition  that  milk  modification  is  so  complex 
a  procedure,  even  when  most  scientific,  that  only  a  baby  specialist  can 
understand  it  and  only  a  trained  nurse  prepare  it.^ 

In  Cleveland  about  ninety  per  cent  of  the  milk  distrib- 
uted "is  sent  out  in  the  form  of  pints  and  quarts  and  only 
ten  per  cent  in  the  so-called  modified  form." 

The  reason  for  this  is  to  teach  as  many  mothers  as  possible  how  to 
prepare  the  food  for  their  own  baby,  and,  therefore,  only  when  the  child 
is  too  ill  or  the  mother,  for  some  reason  or  other,  is  unable  to  properly 
prepare  her  baby's  food,  does  the  Central  Milk  Laboratory  modify 
the  milk  and  put  it  up  in  individual  feeding  bottles.  This  system  has 
been  followed  out  since  the  birth  of  [this]  institution  in  1906.^ 

Moreover,  the  cost  of  modification  at  milk  stations  must 
be  considered.  The  New  York  Milk  Committee  found 
that  to  modify  and  deliver  cost  28  cents  a  quart. 

(3)  Home  pasteurizatioji.  Except  when  the  milk  supply 
is  of  the  highest  character  it  should  be  pasteurized,  and 
nearly  all  authorities  advise  that  it  be  pasteurized  in  any 
case  in  order  to  guard  against  infection.  The  arguments 
for  pasteurization  will  be  reviewed  in  Chapter  III.  When 
the  pasteurization  is  not  performed  before  delivery  of  the 
milk  it  may  be  performed  at  home,  even  without  special 

1  Levy,  in  Rpt.  of  Pub.  Welfare  Com.  of  Essex  County,  N.  J-,  already 
cited,  p.  10. 

2  Rpt.  of  Babies'  Dispensary  and  Hospital  already  cited,  p.  22. 


312  A   MANUAL   FOR   HEALTH   OFFICERS 

apparatus.^     It  should  be  noted,  however,  thai  some  autlior- 
ities  (e.g.,  Strauss  and  E.  B.  Jordan)  are  sceptical  as  to 

'  At  the  Philadelphia  Milk  Show  of  1912  the  following  home  method 
of  pasteurizing  feeding  mixtures  was  given.  Of  course  the  proper  time 
to  pasteurize  is  after  making  up  the  mixtures. 

Articles  Acceded 

"  One  kettle  large  enough  to  hold  eight  bottles  standing  upright. 
"  One  kettle  about  twice  the  size  of  the  first,  with  a  cover. 

Method 

"  Place  bottles  containing  the  milk  mixture  in  the  small  kettle. 
Nearly  fill  with  cold  water.  Place  this  in  the  large  covered  kettle, 
half  full  of  boiling  water  and  allow  to  simmer  gently  for  eight  minutes. 
Remove  from  the  fire,  let  stand  for  one-half  hour  (keeping  covered). 
Then  take  out  bottles,  cool  rapidly  and  place  on  ice." 

The  following  method  for  pasteurizing  milk  in  regulation  bottles 
when  it  is  not  necessary  to  modify  it  and  prepare  feedings  is  given  by 
the  Chicago  Dept.  of  Health. 

"  In  a  small  tin  pail  place  a  saucer;  on  the  saucer  stand  the  bottle 
of  milk  (leaving  the  cap  on  the  bottle).  Now  pour  sufficient  hot  water 
(not  so  hot  as  to  break  the  bottle)  into  the  pail  to  fill  same  to  within 
three  or  four  inches  of  top  of  bottle  and  then  stand  the  pail  and  its  con- 
tents on  the  stove.  The  instant  the  water  begins  to  boil  remove  the 
bottle  of  milk  from  the  pail  and  cool  it  as  rapidly  as  possible. 

"  Keep  the  bottle  of  milk  in  the  ice-box  and  keep  the  cap  on  the 
bottle  when  not  in  use.  When  you  remove  the  cap  do  so  with  a  clean 
fork  prong  and  be  careful  that  the  milk  side  of  the  cap  does  not  come  in 
contact  with  anything  dirty." 

The  following  method,  in  which  the  temperature  is  controlled  by 
means  of  a  thermometer,  is  given  by  L.  A.  Rogers  of  the  U.  S.  Bureau  of 
Animal  Industry  (quoted  by  Magruder): 

"  Milk  is  most  conveniently  pasteurized  in  the  bottles  in  which  it  is 
delivered.  To  do  this  use  a  small  pail  with  a  perforated  false  bottom. 
An  inverted  pie-tin  with  a  few  holes  punched  in  it  will  answer  the  pur- 
pose. This  will  raise  the  bottles  from  the  bottom  of  the  pail,  thus  al- 
lowing a  free  circulation  of  water  and  preventing  bumping  of  the  bottles. 
Punch  a  hole  through  the  cap  of  one  of  the  bottles  and  insert  a  thermom- 
eter. The  ordinary  floating  type  of  thermometer  is  likely  to  be  inaccu- 
rate, and  if  possible  a  good  thermometer  with  the  scale  etched  on  the 
glass  should  be  used.  Set  the  bottles  of  milk  in  the  pail  and  fill  the  pail 
with  water  nearly  to  the  level  of  the  milk.     Put  the  pail  on  the  stove 


the  practicability  of  Ihc  process  in  many  cases,  apd  that 
pasteurization  by  the  (Icalcr,  iinrlcr  aflcfiuatc  sujxTvision,  is 
to  be  j)rcf erred. 

(4)  The  care  of  milk  in  the  home,  though  obviously  im- 
portant, is  frequently  neglected.  Carelessness  and  igno- 
rance in  this  regard  may  largely  nullify  the  benefits  of 
the  best  milk  inspection.  Circulars  on  the  subject  have 
been  issued  by  a  number  of  health  departments.  A  de- 
tailed one  is  published  by  the  New  York  Association  of 
Sanitary  Milk  Dealers.  The  gist  of  them  is  to  "keep  the 
milk  cold,  keep  it  clean  and  keep  it  covered."  In  order 
to  keep  down  the  ice-bill  and  provide  a  simple  and  inex- 
pensive means  of  refrigerating  milk  it  is  advisable  to 
recommend,  where  nothing  more  pretentious  can  be  had,  a 
home-made  ice  box.^ 

or  over  a  gas  flame  and  heat  it  until  the  thermometer  in  the  milk  shows 
not  less  than  150  nor  more  than  155°  F.  The  bottles  should  then  be 
removed  from  the  water  and  allowed  to  stand  from  twenty  to  thirty 
minutes.  The  temperature  will  fall  slowly,  but  may  be  held  more 
uniformly  by  covering  the  bottles  with  a  towel.  The  punctured  cap 
should  be  replaced  with  a  new  one,  or  the  bottle  should  be  covered  with 
an  inverted  cup. 

"  After  the  milk  has  been  held  as  directed  it  should  be  cooled  as 
quickly  and  as  much  as  possible  by  setting  in  water.  To  avoid  danger 
of  breaking  the  bottle  by  too  sudden  change  of  temperature,  this  water 
should  be  warm  at  first.  Replace  the  warm  water  slowly  with  cold 
water.  After  cooling,  milk  should  in  all  cases  be  held  at  the  lowest 
available  temperature. 

"  This  method  may  be  employed  to  retard  the  souring  of  milk  or 
cream  for  ordinary  uses.  It  should  be  remembered,  however,  that 
pasteurization  does  not  destroy  all  bacteria  in  milk,  and  after  pasteuri- 
zation it  should  be  kept  cold  and  used  as  soon  as  possible.  Cream 
does  not  rise  as  rapidly  or  separate  as  completely  in  pasteurized  milk  as 
in  raw  milk." 

^  "  Many  are  unable  to  buy  enough  ice  in  summer  to  preser\-e  milk 
in  ordinary  refrigerators  for  twenty-four  hours.  Most  mothers,  however, 
buy  a  five-  or  ten-cent  cake  every  morning  and  by  following  the  sugges- 
tion of  Dr.  Alfred  F.  Hess  [N.  Y.  Dept.  of  Health]  can  make  at  home  at 
small  cost  an  excellent  milk  refrigerator  that  requires  only  a  ver\-  little 
ice.  .  .  .     His  device  has  been  recommended  for  use  by  the  health 


314  A  MANUAL   FOR  HEALTH  OFFICERS 

Ventilation.  —  The  potent  influence  of  the  heat  and 
ventilation  in  apartments  has  been  the  subject  of  consider- 
able recent  study,  as  a  result  of  which  it  is  seen  that  bad 
conditions  in  these  respects  increase  not  only  diseases  of 
the  respiratory  organs  but  also,  through  disturbances  of 
the  delicate  circulation  and  nervous  system  of  the  child, 
disorders  of  the  gastrointestinal  tract.  We  now  know  that 
the  worst  effects  of  bad  ventilation  and  of  the  stagnant 
summer  heat  in  tenements  are  due  to  heat  and  humidity  and 
not  to  any  fancied  increase  in  carbon  dioxide.  The  sum- 
mer season  is  especially  critical.  Winslow^  has  studied 
the  subject  in  some  detail  and,  quoting  Holt  and  Park 
and  other  authorities,  has  brought  out  especially  the  rela- 
tion between  summer  heat  and  infant  health.  Aside  from 
the  effect  of  the  heat  on  milk  supplies,  he  brings  evidence 
to  show  that  "summer  heat  per  se  has  an  important  effect 
on  infant  mortality,"  with  a  conclusion  that  "heat  may  be 
extensively  fatal  only  when  combined  with  an  abnormal 
food  supply,  but  temperature  is  one  of  the  two  important 

authorities  of  New  York,  Chicago,  Philadelphia  and  other  cities.  Where 
nurses  have  urged  the  mothers  to  construct  this  home-made  refrigerator 
their  attempts  have  met  with  success.  .  .   . 

"  Obtain  a  box  from  the  grocer;  any  wooden  box  a  foot  in  depth  will 
answer  the  purpose.  Buy  a  tin  pail  with  a  cover,  one  deep  enough  to 
hold  a  quart  bottle  of  milk,  and  a  slightly  larger  pail  without  a  cover. 
Place  one  inside  the  other,  and  stand  them  in  the  center  of  the  box. 
Now  pack  sawdust  or  excelsior  beneath  and  all  about  them  to  keep  the 
heat  from  getting  in;  complete  the  refrigerator  by  nailing  about  fifty 
layers  of  newspaper  to  the  under  surface  of  the  box  cover. 

"  The  refrigerator  is  now  ready  for  use.  In  the  morning  as  soon  as 
the  milk  is  received,  it  should  be  placed  in  the  pail  and  five  cents'  worth 
of  ice  should  be  cracked  and  placed  about  the  milk  bottle.  The  cover 
should  be  replaced  on  the  can  and  the  lid  on  the  wooden  box.  Every 
morning  the  melted  ice  should  be  poured  off."  —  The  Survey,  June  25, 

1910,  p.  504. 

*  Winslow,  "  The  Relation  between  Bad  Ventilation  and  Infant 
Mortality,"   Trans.  Atn.  Assn.  for  Study  and  Prevention  of  Inf.  Mart., 

191 1,  p.  149. 


CFiiM)  (iy(;ii;nk  315 

cooperating  causes  and  jK'rliaps  llie  more;  far-rcacliinj^  <>{ 
the  two  in  its  effects."  Schcreschcwsky  has  later  made 
a  detailed  study  of  the  relation  of  heat  to  infant  mortality, 
as  a  result  of  which  he  concludes  that  "the  action  of  heat 
as  a  direct  cause  in  the  summer  mortality  of  infants  has 
been  greatly  underestimated.  ...  In  the  future  much 
more  weight  should  be  given  to  its  influence,"  and  dwells 
on  the  importance  of  indoor  temperature,  which  may  be 
excessive  even  when  the  outdoor  temperature  is  not.^  It 
is  the  duty  of  the  infant  hygiene  nurse  to  prevent  the 
effects  of  hot,  humid  and  stagnant  air  by  securing  proper 
ventilation  in  homes  at  all  sciisons.  The  question  is,  of 
course,  closely  connected  with  overcrowding  and  poor 
housing. 

Clothing. — This  is  a  matter  related  to  the  one  just 
discussed.  The  prevailing  faults  here  are  tight  clothing 
which  restricts  the  circulation  and  movements  of  infants 
and  the  overdressing  of  them  in  warm  weather,  when, 
frequently,  very  little  clothing  indeed  is  needed. 

Nostrums,  "Pacifiers,"  Etc.  —  Discouragement  of  the 
use  of  all  remedies  and  drugs  not  prescribed  by  the  physician 
as  well  as  of  the  various  mechanical  "pacifiers,"  such  as 
false  nipples,  etc.,  is  important." 

Communicable  Disease.  —  Under  this  head  is  included 
protection  of  the  child  against  possible  modes  of  infection 
and  against  dust  and  dirt  and  flies  which  may  be  the  vehicles 
of  it;  also  the  watching  for  possible  infection  of  the  eyes 
by  gonococcus,  etc.  Early  vaccination  of  infants  also 
should  be  urged;  babies  may,  if  healthy,  be  vaccinated  as 
early  as  the  third  or  fourth  month. 

Many  of  the  diarrhoeas  of  infants  are  infectious;  hence 
in  such  cases  the  excreta  and  soiled  articles  should  be  dis- 
infected in  order  to  protect  other  young  children  in  the 
family.     It   has    been    suggested    that    infantile    diarrhoea 

^  Schereschewsky,  "  Heat  and  Infant  Mortality,"  Trans.  Am.  Assn. 
for  Study  and  Prevention  of  Inf.  Mart.,  1913,  p.  99. 


3l6  A  MANUAL  FOR  HEALTH  OFFICERS 

be  made,  for  purposes  of  study  and  control,  a  notifiable 
disease. 

The  nurse  also  supervises  the  hygiene  of  sleeping,  bath- 
ing, etc.,  and  endeavors  to  see  that  the  baby  is  taken  to 
the  consultation  once  a  week  to  be  weighed  and  examined. 
General  Functions  of  Nurse.  —  The  frequency  of 
visits  cannot  be  governed  by  arbitrary  rules  but  should  be 
according  to  the  needs  of  the  individual  case.  As  the 
child  grows  older  visits  may  be  made  less  and  less  fre- 
quently and  after  the  age  of  a  year  they  may  perhaps  in 
the  great  majority  of  cases,  if  well,  be  dropped  entirely 
in  favor  of  the  newly-born  which  are  constantly  added  to 
the  visiting  list. 

Where  charitable  aid  is  necessary  the  nurse  will  refer 
the  case  to  the  proper  organization.  She  can  be  on  the 
lookout  for  unreported  cases  of  ophthalmia  and  keep  a 
general  observation  on  the  work  of  midwives.  She  may 
discover  unreported  births.  She  should  also  act  in  a 
general  way  as  inspector  and  report  unsanitary  conditions 
to  the  department  of  health.  Even  when  maintained  by 
an  unofficial  organization  she  should  be  appointed  a  special 
inspector  by  the  board  of  health. 

In  qualification  the  nurse  should  be  a  graduate  of  a  good 
hospital  training  school,  preferably  with  some  special  ex- 
perience in  baby  work  and  some  knowledge  of  the  methods 
of  social  work.  At  the  present  time  there  is  growing  a 
class  of  nurses  trained  especially  for  public  health  work. 
In  work  among  foreign  races  some  knowledge  of  the  lan- 
guages and  dialects  encountered  is  desirable,  though  not 
absolutely  essential;  interpreters,  e.g.,  intelligent  older 
children  or  "little  mothers,"  may  be  found,  and  it  is  wiser 
to  obtain  superior  ability  and  personality  on  the  part  of 
the  nurse  than  this  special  advantage. 

In  her  relation  to  the  family  the  nurse  acts  as  general 
adviser  in  all  matters  hygienic  and  arranges  the  details  in 
regard  to  milk  stations,  diet  kitchens  and  other  external 


CFHIJ)    IIYMRNE  317 

agencies.  In  her  relation  lo  llic  mcflical  profession  she 
preserves  an  atl.itudc  of  imparliahty  and  flefcrcnce.  Where 
there  is  a  family  physician  she  acts  only  with  his  consent 
and  aids  in  the  accomplishment  of  his  instructions.  Where 
there  is  no  physician  the  family  may  make  its  own  choice 
of  one  or  take  the  infant  to  a  clinic.  Where,  of  course, 
the  case  is  beyond  ordinary  care  on  the  part  of  mother 
and  nurse  and  medical  attention  is  desirable,  she  urges 
that  it  be  obtained. 

When  there  is  a  consultation  or  milk  station,  the  nurse 
assists  at  it,  following  her  cases  there  as  well  as  at  home. 
When  the  work  is  under  private  auspices  small  fees  may  be 
taken  in  some  cases,  but  where  it  is  under  public  control 
there  are  none.  Nurses  should  work  under  the  health 
officer  or  under  proper  medical  control,  and  undertake  no 
duties  and  assume  no  responsibilities  which  should  properly 
be  restricted  to  the  physician,  such  as  the  prescribing  of 
medicines,  special  diets  and  the  like. 

When  babies  under  her  care  are  sick,  the  nurse  should 
give  them  as  much  nursing  attention  as  is  consistent  with 
her  duties  towards  other  cases;  this  is  not  only  a  direct 
benefit  to  the  case,  but  it  also  wins  attachment  and  con- 
fidence among  the  people.  When,  however,  the  nursing 
care  demanded  is  more  than  she  can  manage  with  due 
respect  to  her  other  cases,  then  the  services  of  a  district 
nurse  may  be  called  into  requisition. 

Finally,  the  nurse  should  teach  mothers  to  be  capable 
and  self-reliant,  so  that  they  will  not  need  to  depend  upon 
the  nurse  at  every  turn.  A  nurse  may  be  an  excellent 
helper  herself  and  yet  leave  the  mother  as  helpless  and 
incompetent  as  before  she  was  called  in.  On  the  contrary, 
the  mother  should  be  taught  so  that  she  may  not  only  help 
herself  in  future,  but  so  that  she  may  also  be  helpful  to  her 
friends  and  neighbors.^ 

1  For  further  details  on  organization  see  "  New  Zealand  Society  for 
the  Health  of  Women  and  Children:  An  Example  of  Methods  of  Baby- 


3l8  A   MANUAL    rOR    IIKALTII   OFFICKRS 

4.  Consultation  and  Milk  Stations  {"Infant  Welfare 
Stntions'').  —  Infants'  consultation  classes  are  an  out- 
growth of  the  milk  station  system  for  the  distribution  of 
superior  grades  of  milk.  When  this  milk  was  modified 
it  was  found  necessary  to  have  babies  brought  to  the 
station  for  examination  so  that  the  formula  might  be 
adapted  to  the  individual  child;  hence  the  consultation 
class.  It  is  now,  however,  generally  agreed  that  the  prime 
function  of  milk  stations  is  to  keep  babies  under  expert 
supervision  and  the  mothers  under  medical  instruction. 
Whatever  a  station  may  stand  for  in  theory,  the  weekly 
weighing  and  examination  of  babies  and  free  advice  to 
mothers  take  the  chief  position,  while  the  supplying  of 
milk  is  simply  an  adjunct  and  an  attraction.  While  the 
character  of  milk  supplies  is  unquestionably  important, 
the  relative  weight  accorded  to  milk  stations  as  such  has 
been  lessened  by  three  things:  the  placing  of  the  emphasis 
on  maternal  nursing  rather  than  upon  the  facility  of  ob- 
taining milk  for  artificial  feeding,  the  teaching  of  the  home 
modification  of  milk,  and  the  improvement  of  market 
milk  supplies  for  infant  use  which  has  been  taken  up  in 
many  places.  In  any  event  it  is  a  mistake  to  lead  the 
public  to  suppose  that  such  stations  are  chiefly  for  the  dis- 
pensing of  milk  to  the  exclusion  of  factors  of  more  general 
importance.  The  warning  note  against  placing  too  much 
dependence  upon  the  simple  pure-milk  station  is  sounded 
in  the  following:  ^ 

The  evolution  of  the  infants'  milk  station  is  essential.  Pure  milk, 
however  desirable,  will  never  alone  solve  the  infant-mortality  problem. 


saving  Work  in  Small  Towns  and  Rural  Districts,"  Bureau  Publication, 
no.  6,  U.  S.  Children's  Bureau,  1914;  and  for  a  precis  of  details  of  in- 
fant hygiene  "  The  Care  of  the  Baby,"  Supplement  no.  ID  to  the  Public 
Health  Rpts.,  U.  S.  Public  Health  Service,  1914,  and  "Infant  Care," 
free  pamphlet  of  U.  S.  Children's  Bureau. 

1  Dr.  Josephine  Baker,  director  of  child  hygiene  of  the  department  of 
health  of  New  York  City,  Trans.  X  V  Inlcrnat.  Congress  on  Hyg.  and 
Demography,  1912,  vol.  Ill,  p.  149. 


CHILI)  iiy(;ii;nk  319 

Under  our  system  of  home  visiting  to  instruct  mothers  in  the  care  of 
babies  we  have  demonstrated  that  babies  may  be  kept  unrler  contin- 
uous supervision  at  the  cost  of  60  cents  per  month  per  baby,  and  the 
death  rate  auKjng  babies  so  cared  for  by  us  has  been  1.4  per  cent.  The 
death  rate  among  babies  under  the  care  of  the  mili<  stations  has  been  2.5 
per  cent,  and  the  cost  $2  per  month  per  baby.  Without  overlooking 
the  value  of  pure  milk,  I  believe  this  problem  must  primarily  be  solved 
by  educational  measures.  In  other  words,  the  solution  of  the  problem 
of  infant  mortality  is  20  per  cent  pure  milk  and  80  per  cent  training  of 
the  mothers.  The  infants'  milk  stations  will  serve  their  wider  useful- 
ness when  they  become  educational  centers  for  prenatal  instruction 
and  the  encouragement  of  breast  feeding  and  teaching  better  hygiene, 
with  the  mother  instructed  to  buy  the  proper  grade  of  milk'  at  a  place 
most  convenient  to  her  home. 

The  following  extracts  on  the  methods  and  organization 
of  infant  welfare  stations  are  taken  from  a  valuable  bulletin 
issued  by  the  New  York  State  Department  of  Health.^ 

Methods.  —  Although  the  stations  are  usually  called  "infants' 
milk  stations,"  the  dispensing  of  milk  is  now  universally  recognized 
as  but  a  minor  part  of  the  work  of  the  station.  In  fact,  a  better  and 
more  descriptive  name  for  the  stations  would  be  "  infant  welfare  sta- 
tions." It  is  true  that  the  sale  of  milk  attracts  the  mothers,  and  at 
Yonkers  certified  milk  is  sold  two  cents  below  the  market  price  with 
the  intention  of  drawing  mothers  to  the  station.  But  with  the  progress 
of  rigid  city  milk  inspection,  such  as  is  now  organized  in  several  cities, 
the  importance  of  dispensing  pure  milk  decreases  and  the  educational 
features  of  the  work  expand.  In  many  of  the  cities  considered,  the  milk 
sold  at  the  stations  was  not  certified  but  the  best  obtainable  from  regu- 
lar market  sources,  an  endorsement  of  the  good  quality  of  the  milk 
sold  in  those  cities. 

A  brief  summary  of  the  work  in  the  twelve  communities  is  given  at 
the  end  of  this  report.  A  medical  director  is  usually  appointed  to  have 
charge  of  the  entire  work  of  the  welfare  station.  Two  or  more  physicians 
cooperate  with  him  and  are  assigned  days  at  the  babies'  clinics.  Usually 
a  physician  is  asked  to  serve  on   consecutive   clinic   days,  the  season 

'  In  New  York  City  market  milk  is  graded  and  marked  so  that 
grades  fit  for  infants  can  be  distinguished.  —  The  Author. 

^  Monthly  Bulletin,  N.  Y.  State  Dept.  of  Health,  Dec,  1913.  See 
also  Special  Bull,  of  Same  Dept.  on  Conference  on  Infant  Welfare  held 
June,  1913,  containing  important  papers  on  various  aspects  of  the 
subjects. 


320  A  MANUAL   FOR   HEALTH  OFFICERS 

being  divided  up  between  the  medical  director's  assistants.  For  in- 
stance, in  Cohoes  four  doctors  served  twenty-two  days  each  during  the 
three  months  the  station  was  in  operation.  This  method  has  the  ad- 
vantage of  securing  more  uniformity  of  treatment  than  where  the 
doctors  serve  aUernate  weeks.  To  secure  the  best  results  with  volunteer 
physicians  a  uniform  course  of  treatment  and  care  should  be  agreed 
on  and  any  deviation  from  it  be  made  only  in  consultation  with  the 
medical  director. 

The  work  of  the  nurses  is  divided  into  examining  the  babies  at  the 
station,  dispensing  milk  and  visiting  the  babies  in  their  homes.  Home 
visits  are  of  the  greatest  importance.  In  Poughkeepsie  as  many  babies 
are  visited  in  their  homes  as  are  enrolled  at  the  station.  In  Yonkers 
the  nurses  are  supplied  every  week  with  lists  of  all  births  in  their  dis- 
tricts, and  the  babies  are  visited  immediately.  This  is  a  plan  which 
should  be  recommended  to  all  stations  as  worthy  of  adoption.  Of  course, 
discretion  is  used  in  utilizing  these  lists,  as  it  is  obvious  that  some  of  the 
babies  in  certain  streets  will  be  well  cared  for  and  need  not  be  visited. 

The  cooperation  of  the  physician  in  a  community  where  a  milk 
station  is  established  is  most  important.  It  is  surprising  that  there 
has  been  opposition  to  the  work  by  physicians  in  some  cities,  but  this 
opposition  is  being  overcome.  Cards  are  given  to  all  physicians  in 
Utica  for  use  in  referring  their  patients  to  the  stations.  Also  in  many 
cities  the  services  of  the  nurses  are  offered  for  any  case  which  private 
practitioners  may  have,  where  the  mother  is  too  poor  to  pay  for  such 
services. 

The  problem  of  location  of  a  station  has  been  met  in  some  cities  as 
Rochester,  Utica,  Little  Falls  and  Syracuse  by  utilizing  the  public 
schools  during  the  vacation  period.  In  Buffalo  rooms  are  used  in 
settlement  houses.  The  rooms  should  be  large  and  light,  with  a  smaller 
room  in  the  rear  where  private  consultations  may  be  held.  A  large 
room  offers  a  fine  opportunity  for  talks  to  mothers  on  other  days  than 
clinic  days,  as  is  done  at  Poughkeepsie  and  some  other  cities. 

To  date,  little  emphasis  is  placed  on  work  among  expectant  mothers 
in  the  stations  considered.  Usually,  however,  when  the  nurse  hears  of 
an  expectant  mother,  she  visits  her  and  invites  her  to  the  station  to 
attend  the  classes  for  mothers  with  babies.  At  Buffalo  the  nurses  follow 
up  all  cases  heard  of,  as  is  done  in  several  other  cities.  In  Utica  pre- 
natal work  was  begun  in  September  and  is  now  a  part  of  the  regular 
station  routine. 

There  is  no  doubt  but  that  this  work  will  shortly  be  incorporated  in 
every  station's  activities,  although  the  growth  of  the  stations'  clientele 
to  the  present  time  has  been  so  great  that  additional  activities  could  not 
very  well  be  undertaken. 


ciiiiJ)  jiy(;ii;nI';  321 

Records.  —  In  a  review  of  Uie  work  of  the  infant  welfare  afaliona 
in  the  State  the  matter  of  records  of  the  work  is  <>(  great  interest.  In 
most  instances  the  family  histories  of  the  bajjy  and  weekly  histories  of 
its  condition  are  kci)t  with  more  or  less  uniformity.  Printed  forma 
for  daily  or  monthly  summaries  are  used  at  Yonkers,  Buffalo,  Rochester 
and  Schenectady.  While  daily  reports  are  hardly  needed  when  there 
is  only  one  station,  a  weekly  or  monthly  compilation  of  the  condition 
of  the  babies  and  work  of  the  station  Is  extremely  necessary.  A  com- 
plete weekly  or  monthly  record  of  the  attendance  and  condition  of  the 
babies  at  a  station,  together  with  a  report  of  the  activities  of  the  nurse, 
such  as  visiting,  etc.,  is  needed  for  guidance  of  the  medical  director  and 
for  public  proof  of  the  value  of  the  work.  The  principal  record  and 
report  forms  used  at  the  stations  are  reproduced.'  They  furnish  an 
interesting  study  of  the  records  employed  in  the  different  cities. 

Relief  Work.  —  Infant  welfare  stations,  although  at  present  largely 
supported  by  private  funds,  are  in  no  sense  a  charity.  Through  the 
example  of  the  New  York  and  Rochester  municipalities,  the  work  has 
been  placed  on  the  same  basis  as  that  of  the  public  school.  In  some 
communities  it  is  extremely  necessary  to  exclude  any  idea  of  charity,  or 
mothers  will  not  attend  the  station.  It  is  not  only  the  very  poor  who 
make  up  the  clientele  of  the  stations,  but  many  mothers  attend  who  are 
referred  there  by  their  family  physicians,  and  who  are  anxious  to  have 
the  nurse  teach  them  the  proper  care  of  their  babies. 

Sometimes,  however,  relief  Is  urgently  needed,  for  instance,  by  a 
very  poor  family  when  the  husband  is  out  of  work.  So  arrangements 
are  usually  made  by  the  station  management  for  the  temporary  pay- 
ment for  the  milk  In  such  cases. 

In  five  of  the  cities  the  stations  have  funds  for  paj-ment  for  milk 
when  the  mother  Is  unable  to  do  so.  Four  other  cities  refer  relief  cases 
to  private  or  city  charities.  One  station  reported  no  relief  given  at  all. 
In  all  cases  little  relief  was  given  as  the  price  of  the  milk  Is  generally 
the  same  or  lower  than  the  market  price  of  ordinary-  milk,  and  few 
mothers  are  not  able  to  pay.  It  Is  evident  from  the  survey  of  the 
stations  Included  in  this  report  that  free  milk  or  partly  free  milk  for 
mothers  Is  an  extremely  small  item  in  the  management  of  a  station. 
At  Utica  it  was  found  that  mothers  would  not  come  to  a  place  where 
"  charity  milk  "  was  given.  To  overcome  this  a  small  donation  was 
given  by  the  milk  station  committee  to  the  local  charity  organization 
society  to  whom  all  cases  for  relief  were  referred.  This  donation 
amply  covered  the  free  or  partly  free  milk  given  b\'  the  station  this 
summer. 

^  On  account  of  lack  of  space  the  records  and  forms  unfortunately 
cannot  be  reproduced  here. 


322  A   MANUAL   FOR   HEALTH   OFFICERS 

Literature  for  Distribution.  —  Almost  all  the  stations  have  printed 
leaflets  or  cards  with  brief  advice  to  mothers  on  the  care  of  the  baby. 
Some  of  these  have  Ijeen  printed  in  five  languages  as  at  the  Rochester 
stations.  As  the  majority  of  the  mothers  who  attend  the  stations  are 
foreigners,  simple  leaflets  in  other  languages  than  English  are  of  value. 
The  Department's  booklet  on  "  How  to  Save  the  Baby  "  is  distributed 
in  many  of  the  cities. 

SUGGESTIONS   FOR   THE   ORGANIZATION    OF   INFANT 
WELFARE   STATIONS 

Infant  welfare  or  milk  stations  arc  now  considered  as  educational 
centers  for  mothers,  rather  than  simpl\-  places  where  pure  milk  for 
babies  may  be  bought.  As  early  as  1897  two  infant  milk  stations  were 
opened  in  Rochester,  these  being  the  first  outside  of  New  York  City. 
Previous  to  that  the  work  had  been  started  in  New  York  City  as  far 
back  as  1873  by  the  New  York  Diet  Kitchen  Association,  which  fur- 
nished nourishing  food  and  pure  milk  to  the  poor. 

The  work  of  an  infant  welfare  station  consists  of  dispensing  pure 
milk  to  mothers  for  themselves  or  their  babies,  and  teaching  the  mothers 
how  to  take  proper  care  of  their  babies.  In  many  stations  prenatal 
work  is  also  undertaken. 

Organization.  —  In  some  cities  the  stations  are  supported  by  munic- 
ipal funds,  but  where  this  is  not  possible  a  committee  is  formed  who 
raise  the  necessary  money  and  manage  the  work.  A  medical  director 
is  appointed  who  has  direct  charge  of  the  work.  The  staff  consists  of 
at  least  one  nurse  for  each  station  and  several  volunteer  physicians 
who  have  charge  of  the  weekly  clinics. 

Financing.  —  The  first  work  after  the  organization  of  the  committee 
is  the  raising  of  funds.  From  reports  of  the  work  in  the  State  this 
has  not  been  a  very  difficult  matter.  One  city  actually  has  had  sub- 
scribed twice  as  much  money  as  it  could  use  last  summer.  In  Utica 
milk  bottles  with  slit  tops  were  placed  in  various  public  places,  such  as 
drug  stores,  libraries,  etc.,  and  by  this  novel  and  appropriate  method 
a  large  sum  was  collected.  Other  means  of  raising  funds  readily  suggest 
themselves  so  that  this  part  of  the  work  will  not  be  considered  at  length. 

Location.  —  The  station  should  be  opened  as  near  to  the  center  of 
the  district  it  is  to  serve  as  possible.  A  study  of  the  location  of  infant 
deaths  in  a  city  will  show  better  than  any  other  method  where  a  station 
had  best  be  placed.  Rent  can  be  saved  if  the  cooperation  of  a  settle- 
ment house  can  be  secured  and  the  station  installed  there,  as  at  Albany. 
In  Syracuse,  Rochester,  Little  Falls  and  several  other  cities  rooms  in  the 
public  schools  were  utilized  during  the  summer  vacation  for  this  pur- 
pose.    Where  such  plans  are  not  practicable  for  the  housing  of  the 


CITIIJ)    IIVGrKNK  323 

station,  the  rciitiiij;;  of  a  store  is  necessary.  In  several  cities,  notably 
Yonkers  and  Schenectady,  this  has  i)een  done  with  ^reat  success,  as  a 
store  can  iisnally  l)c  rented  in  tiie  iicarl  (jf  any  district  to  be  servcfl. 

Size  of  Station.  —  Two  rooms  at  least  are  necessary  for  the  station. 
One  should  jje  a  large  milk-dispensing  room  and  suitable  for  the  holding 
of  classes  for  mothers.  Camp  chairs  are  excellent  for  use  here,  as, 
when  the  class  is  over  they  may  be  folded  up  and  put  aside,  allowing 
free  use  of  the  floor  space.  A  smaller  room  at  the  rear  of  the  dispens- 
ing room  will  serve  for  a  consultation  and  weighing  room.  Here  the 
doctor  in  charge  and  the  nurse  examine  and  weigh  the  babies  at  the 
weekly  clinic.  This  room  should  be  supplied  with  running  water 
and  arrangements  for  heating  water,  etc.  The  consultation  room  may 
also  be  utilized  as  a  demonstration  room  for  demonstrating  modification 
of  milk  to  mothers. 

Equipment.  —  F'or  the  dispensing  room  the  principal  equipment 
required  is  an  ice  box  where  the  milk  bottles  can  be  placed  in  direct 
contact  with  the  ice,  [which]  is  preferable  to  one  where  the  ice  is  kept  in 
a  separate  compartment.  A  table  for  the  nurse  is  needed,  also  sufficient 
chairs  for  nurse  and  mothers.  If  classes  are  held,  a  number  of  folding 
camp  chairs  will  be  necessary.  The  consultation  room  contains  the 
doctor's  desk  or  table,  table  for  weighing  scales  and  a  cabinet  for  the 
various  supplies.  Also  utensils  for  bathing  the  baby.  [Also  sink  and 
gas  stove.] 

Dispensing  of  Milk.  —  Milk  is  bought  by  the  station  management 
and  sold  to  the  mothers.  In  stations  where  certified  milk  is  used  the 
market  price  is  usually  prohibitive,  so  it  is  sold  at  cost  or  less.  Milk 
not  certified,  but  of  a  good  grade,  is  dispensed  in  many  stations,  and  in 
cities  where  there  is  an  efficient  system  of  milk  inspection  this  milk 
attains  a  high  standard.  Where  there  are  many  stations  the  method 
employed  by  the  New  York  City  Health  Department  for  the  dispensing 
of  the  milk  might  be  employed.  There  the  milk  is  sold  for  the  dealer 
in  each  station  by  matrons  who  are  responsible  to  him  for  the  daily 
receipts. 

Management  of  Work  at  Station.  —  The  nurse  is  in  attendance  at 
the  station  from  about  8:00  a.m.  to  12:00  noon  for  the  purpose  of  dis- 
pensing milk.  In  large  stations,  as  already  stated,  a  matron  is  employed 
to  dispense  the  milk  so  that  the  nurse  will  have  more  time  to  devote  to 
her  other  duties.  Mothers  are  given  advice  in  these  morning  hours,  and 
on  clinic  days  the  babies  are  weighed  and  new  babies  examined.  In 
the  afternoon  the  nurse  visits  the  mothers  in  their  homes,  teaching  them 
to  modify  the  milk  if  necessary.  This  instruction  to  mothers  is  the 
most  important  part  of  the  work  of  the  nurse.  Milk,  no  matter  how 
pure,  is  harmful  if  given  to  the  baby  in  a  dirty  bottle  or  modified  in 


324  A  MANUAL   FOR  HEALTH  OFFICERS 

dirty  utensils.  Patient  and  persistent  work  on  tlie  part  of  the  nurse 
is  necessary,  and  her  duties  include  the  giving  of  much  advice  on  house- 
hold management. 

In  Yonkers  the  nurses  are  furnished  a  list  of  births  every  week  by  the 
health  department,  and  call  on  the  mothers  at  once.  This  is  an  excellent 
plan  as  it  insures  the  mother  proper  care  for  her  baby  from  the  first. 
In  some  cities  the  nurses  make  a  point  of  visiting  expectant  mothers  and 
hold  classes  for  them  at  the  stations.  This  is  comparatively  new  work 
and  is  rapidly  becoming  a  feature  of  welfare  station  activities.  The 
doctor  assigned  to  the  station  has  at  least  one  clinic  a  week,  where  babies 
are  weighed  and  new  babies  examined.  Sick  babies  are  referred  by 
him  to  the  family  physician  or  a  hospital  or  dispensary,  and  mothers  of 
sick  babies  are  instructed  in  the  proper  care  of  them.  Where  the  baby 
is  too  ill  to  be  brought  to  the  welfare  station  the  doctor  visits  with  the 
nurse  and  takes  charge  of  the  case  if  the  family  cannot  afford  to  pay  for 
the  ser\-ices  of  an  outside  physician.  The  matter  of  treating  babies  by 
the  welfare  station  doctor  is  a  rather  delicate  one,  as  some  opposition 
will  develop  toward  the  work  by  misguided  physicians  who  believe  that 
free  treatments  and  advice  will  hurt  their  practice.  Mothers  are  al- 
ways referred  to  their  own  physicians  and  encouraged  to  go  to  them. 
The  services  of  the  nurse  are  always  free  to  all  doctors  of  the  com- 
munity- where  they  have  sick  babies  which  need  such  care. 

Records.  —  In  organizing  a  station  two  records  are  absolutely  neces- 
sary. Others  may  be  added  as  the  work  grows  and  the  need  is  felt  for 
them.  The  two  are  the  registration  card  and  the  weekly  or  monthly 
report  form  compiled  from  information  recorded  on  the  registration 
card.  The  following  forms'  are  recommended,  having  been  prepared 
with  a  view  to  simplicity  and  efficiency.  A  well-managed  station, 
even  if  small,  should  have  complete  records  of  its  work,  and  the  forms 
should  be  so  designed  as  to  give  this  information  in  the  clearest  and 
most  available  manner. 

These  forms  have  been  prepared  for  use  after  a  study  of  the  needs 
and  requirements  of  the  welfare  stations  in  cities  of  varying  sizes  in  the 
State.  Simplicity  has  been  aimed  at  and  only  the  most  essential  in- 
formation is  noted.  Data  of  a  purely  sociological  character,  although 
valuable  in  determining  the  economic  and  social  position  of  the  families, 
has  been  omitted  as  not  of  immediate  importance  and  likely  to  unduly 
complicate  the  records. 

The  vertical  record  registration  card  reproduced  has  been  made  as 
self-explanatory  as  possible.     The  vertical  weight  and  feeding  chart  on 
the  left  gives  at  a  glance  the  gain  or  loss  in  weight  together  with  the  kind 
and  changes  of  feeding. 
1  See  the  Bulletin  for  these  forms,  which  cannot  be  reproduced  here. 


CHILI)    IIYCMKNIO  325 

Below  the  registration  record  is  the  prenatal  record  for  use  in  expec- 
tant mother  work.  By  including  this  on  the  same  card  the  jjrenatal 
history  is  readily  available  and  it  may  also  be  filled  out  for  babies  whose 
mothers  have  not  been  under  observation  during  jjregnaiu  y,  but  who 
have  brought  their  babies  to  the  staticjn. 

A  comprehensive  report  of  the  w(jrk  at  the  station  whether  comjjiled 
weekly  or  monthly,  should  show: 

(i)   Number  of  babies  at  beginning  of  month. 

(2)  New  babies;   how  referred  to  station. 

(3)  Babies  dropped  from  roll,  and  cause. 

(4)  Babies  on  roll  at  end  of  month. 

(5)  Attendance  of  mothers  at  classes. 

(6)  Condition  of  babies  and  how  fed. 

(7)  Report  of  visits  of  nurse. 

(8)  Quantity  of  milk  sold. 

(9)  Relief  given. 
(10)   Prenatal  work. 

With  this  in  mind  the  accompanying  weekly  or  monthly  report 
blank  is  suggested.  Local  application  of  it  will  probably  call  for  addi- 
tions. When  correctly  filled  out,  the  movement  of  the  station  clientele 
can  be  intelligently  followed,  and  the  improvement  in  the  babies  noted. 
The  cooperation  of  physicians  and  philanthropic  organizations  is  also 
recorded,  and  the  reasons  for  babies  ceasing  to  come  is  shown.  This 
last  is  very  important  where  there  are  many  stations. 

The  reverse  side  of  the  card  contains  the  names  and  addresses  of 
babies  who  have  died  during  the  month.  Also  the  names  of  babies 
transferred  to  hospitals  with  name  of  hospital. 

Relief  Work.  —  There  are  usually  very  few  mothers  who  cannot 
afford  to  pay  the  small  price  asked  for  the  milk.  It  is  best  to  have 
those  who  need  help  in  procuring  milk  for  their  babies  pay  as  much  as 
possible,  even  if  it  is  only  a  few  cents.  A  separate  fund  at  the  disposal 
of  the  welfare  station  for  this  purpose  is  worth  while  as  relief  ma>-  then 
be  given  promptly.  Some  stations  refer  all  cases  to  the  local  charity 
organization  society  for  investigation  and  relief. 

Literature  for  Distribution.  —  The  pamphlet  on  "  How  to  Save  the 
Baby,"  issued  free  by  the  State  Department  of  Health  is  offered  to 
all  stations  for  distribution  to  mothers.  In  some  stations  small  cards 
or  folders  containing  brief  advice  are  distributed.  Where  different 
nationalities  are  served  by  the  station  the  literature  should  be  printed 
in  their  respective  languages. 

Cost  of  Operation.  —  The  monthly  cost  of  operating  the  welfare 
stations  depends  on  many  conditions.     The  principal  expenses  are: 

1.  Salary  of  nurses  and  matrons. 

2.  Rent  of  station. 


326 


A  MANUAL   FOR   HEALTH   OFFICERS 


3.  Equipment. 

4.  Supplies  iboitlcs,  ice,  printing,  etc.). 

5.  Loss  on  siile  of  milk  (if  sokl  less  than  cost). 

In  many  cities  the  use  of  i>ublic  schools  during  the  summer  solves  the 
rent  problem.  In  others  rooms  in  settlement  and  cliurch  houses  may 
be  secured  free  of  charge.  The  equipment  of  a  new  station  is  often 
donated  or  paid  for  by  special  subscription. 

Some  typical  budgets  are  given  below  as  an  indication  of  the  total 
cost  of  operating  a  station  for  the  summer.  In  Utica,  Little  Falls  and 
Syracuse  public  schools  were  utilized  for  quarters,  and  in  Albany  the 
station  was  given  space,  rent  free,  in  the  South  End  Dispensary.  The 
cost  per  month  ranges  from  $129  in  Albany  to  $280  in  Syracuse,  the 
average  being  $195.50.  The  cost  of  equipment  of  all  stations  except 
the  one  in  Albany  is  included  in  the  totals. 

The  monthly  cost  per  baby,  which  is  shown  below,  is  based  on  the 
registration  of  the  stations  for  August  31.  The  actual  cost  is  probably 
a  little  higher,  as  this  is  the  month  of  largest  enrollment.  Invidious 
comparisons  of  these  figures  should  not  be  made,  as  operating  condi- 
tions vary  greatly  in  different  cities.  The  loss  on  the  sale  of  milk,  for 
instance,  is  a  large  item  at  some  stations,  especially  in  those  where 
certified  milk  is  dispensed. 

As  should  be  e.\pected,  a  large  enrollment  decreases  the  cost  per 
baby.  The  budgets  show  a  gradual  decrease  of  cost  per  baby  with 
the  increased  enrollment.  The  number  of  babies  which  one  nurse  can 
care  for  is  limited  by  the  situation  of  the  station  —  whether  the  station 
draws  from  a  congested  neighborhood  or  from  a  widespread  area.  The 
character  of  the  people  living  near  the  station  also  affects  the  enroll- 
ment. In  the  poorer  districts  the  registration  is  usually  much  larger 
than  in  those  sections  of  the  cities  where  the  families  are  better  ofT. 


TYPICAL   BUDGETS   OP  INFANT  WELFARE   STATIONS 


Utica 

Little  Falls 

Albany 

Syracuse 

Average 

per 
station 

Months  open 

July,  Aug. 

I 

$463  00 

382 

$2.31.50 
0.61 

5,335 

6.9 

July,  Aug. 

I 

$281.00 

94 

$140.50 
1.49 

I.188 
6.3 

June,  July, 
Aug. 

I 

$487.00 

69 

$129.00 
1.87 

1,060 
S.I 

July,  Aug. 

2 

$1,122.00 

473 

$280.50 
I. II 

12,440 

II 

Number  of  stations 

Total  disbursements 

Babies  cared  for  (Aug.  31) . 
Total  disbursements  (per 

station  per  month) 

Cost  per  baby  (per  month) 
Total  quarts  of  milk  dis- 

$470.00 
203 

$195. 37 

1.04 

5. 005 J 

Total  quarts  per  baby  (per 

7-7 

CHILD  iiv(;ii;nI':  327 

5.  "Little  Mothers."  —  'Hiis  importanl  ph.isc  of  tlic 
infant  welfare  movement  is  well  descrihcfl  in  tlic  follow- 
ing extract  from  tlie  Bulletin  of  the  (.'hildren's  Ikireau  on 
"  Baby-Saving  Campaigns. " 

"  Little  Mother  Leagues  "  and  "  Little  Mother  Classes  "  in  the 
public  schools  represent  efforts  made  in  New  York,  N.  Y.,  Kansas  City, 
Mo.,  Cleveland,  Ohio,  and  Milwaukee,  Wis.,  to  carry  instruction  into 
the  home  from  another  angle.  "  Little  Mothers  "  are  the  school  girls 
who  have  to  help  care  for  babies  or  for  younger  children  at  home.  Of 
course  the  schools  of  every  city  have  many  such,  and  as  they  live  in  all 
parts  of  the  town  and  come  from  every  class,  it  follows  that  to  reach 
them  is  to  influence  an  ever-widening  circle  of  mothers  and  homes 
where  instruction  is  most  needed.  The  policy  in  New  York  City  was 
to  organize  these  school  girls  who  were  caretakers  of  little  children  into 
groups  and  teach  them  the  care  of  babies.  These  groups  were  called 
"  leagues  "  and  the  whole  organization  was  "  The  Little  Mothers' 
League."  Dr.  Josephine  Baker,  of  the  New  York  division  of  child 
hygiene,  in  a  paper  before  the  International  Congress  of  Hygiene  and 
Demography,  in  September,  191 2,  says: 

The  aid  of  over  20,000  girls  from  12  to  14  years  of  age  was  en- 
listed and  made  of  practical  value  by  the  formation  of  "  Little 
Mothers'  Leagues."  These  are  still  one  of  the  most  important 
branches  of  our  work.  The  girls  are  taught  all  practical  methods 
of  baby  hygiene  and  feeding.  The  potential  value  of  training 
young  girls  for  intelligent  motherhood  is  not  only  of  immense  im- 
portance, but  the  immediate  results  have  been  striking  in  the  im- 
proved care  that  is  given  to  the  babies  who  are  directly  under 
the  care  of  these  young  girls.  As  true  prevention  work,  it  ranks 
of  first  importance  in  the  prevention  of  infant  mortality-  in  this 
and  the  next  generation.  In  all  239  of  these  leagues  were  founded 
in  191 1,  and  practically  an  equal  number  have  been  organized  this 
year  (1912).  Weekly  meetings  are  held  for  instruction.  Each 
league  is  under  the  supervision  of  a  doctor  and  a  nurse  from  the 
division  of  child  hygiene.  Each  weekly  lesson  takes  up  some 
particular  phase  of  baby  care.  The  doctor  gives  a  short,  simple 
talk;  then,  with  the  nurse,  demonstrates  his  subject.  Our  out- 
line embraces  the  importance  of  breast  feeding,  hygiene  of  the 
home,  cleanliness,  ventilation,  etc.,  hygiene  of  the  infant,  includ- 
ing bathing,  dressing  and  ^•alue  of  fresh  air,  infant  feeding,  with 
methods  of  milk  modification.  The  lessons  are  simple  and  prac- 
tical, and  the  children  are  required  to  carry  out  each  part  of  the 
work.     Babies  are  not  lacking  for  demonstration  purposes,   for 


328  A  MANUAL  l-OR   HEALTH   OlTICilRS 

nearly  every  little  mother  brings  her  own  ciuirgc  to  the  meetings, 
and  often  the  rivalry  is  great  to  have  "  my  baby  "  chosen  as  an 
object  lesson  of  health  and  right  living.     The  members  write  and 
act  little  plays,  the  play  always  hinging  upon  some  newly  discov- 
ered way  to  keep  the  baby  well.     The  real  inicjuity  of  lollypops 
and  dill  pickles  as  baby  food  is  being  uncovered,  and  these  and 
kindred    baby    pacifiers   of   former   days   are   being    relegated    to 
oblivion. 
In  Kansas  City  and  in  Milwaukee  all  girls  desiring  to  enter  these 
classes  are  enrolled,  whether  or  not  they  arc  caretakers  of  babies  at 
home.     The    health   department    undertakes   to    teach    l)aby   hygiene 
through  the  public  schools  to  all  girls  who  care  to  avail  themselves  of 
the  opportunity  by  joining  the  classes — a  step,  in  short,  toward  the 
movement  in  French  and  German  schools  in  education  for  mother- 
hood. 

In  Cleveland,  Ohio,  instruction  is  given  to  girls  in  the  seventh  and 
eighth  grades  by  the  introduction  of  an  infant  hygiene  division  in  the 
domestic  science  department  of  the  schools.  On  June  9,  1913,  there 
were  48  classes  a  week,  with  884  girls  taking  the  work.  The  course 
consists  of  six  lessons,  as  follows: 

Lesson  I.  —  How  to  keep  baby  well.  Causes  and  prevention  of 
high  death  rate. 

Lesson  II.  — Growth  and  development  of  normal  baby. 
Lesson  III.  —  Pattern  demonstration.     Each  pupil  cutting  patterns 
for  baby's  outfit. 

Lesson  IV.  —  Feeding:  Maternal  nursing,  artificial  feeding,  dangers 
of  patent  foods.     (Charts  for  five  lessons.) 

Lesson  V.  —  Bath:  Things  necessary,  preparation,  how  much  good 
it  does  baby. 

Lesson  VL  —  Common  illness  among  babies.  First  home  treatment 
in  beginning  of  intestinal  disturbances. 

6.  Milk  Supplies.  —  While,  as  stated  above,  the  role  of 
milk  supplies  in  the  infant  mortality  problem  has  been 
exaggerated  in  proportion  to  other  factors,  nevertheless 
their  absolute  importance  should  not  be  underestimated. 
Unclean,  bacteria-laden  milk  is  responsible  for  a  great  deal 
of  sickness  among  infants,  while  bovine  tuberculosis  in- 
fection through  non-tuberculin-tested  and  unpasteurized 
supplies  constitutes  another  problem.  "It  is  now  esti- 
mated that  perhaps  7  per  cent  of  the  tuberculosis  in  man 


CHILD   HYGIENE  329 

is  of  bovine  origin."  (Rosenau.)  This  is  contracled  through 
milk  and,  according  to  the  opinion  of  many  authorities,  in 
early  infancy.  The  Children's  Bureau  has  this  to  say  of 
milk  supplies: 

The  importance  of  milk  control  in  summer  months  [and,  it  must  Ijc 
added,  at  all  seasons]  cannot  be  overestimated.  Health  officers  are 
practically  as  one  in  the  opinion  that  unclean  milk,  or  the  improper  pre[;- 
aration  and  care  of  milk  in  the  home,  is  responsible  for  a  large  share  of 
the  increase  in  infant  death  rate  that  comes  with  the  heaterl  season.' 

Milk  supplies  will  be  taken  up  in  detail  in  Chai)ter  III. 
The  necessity  for  proper  home  care  of  milk  has  already 
been  considered. 

7.  Housing  and  General  Sanitation.  —  Due  attention 
must  be  paid  to  securing  proper  housing  conditions,  espe- 
cially as  to  light,  ventilation  and  cleanliness.  Other  en- 
vironmental conditions  should  be  looked  after,  breeding 
places  of  flies  and  vermin  removed,  etc.  Recent  research 
tends  to  show  that  flies  play  an  important  part  in  the  pro- 
duction of  infantile  diarrhoea;  not  only  should  measures 
be  directed  toward  suppression  of  breeding  places,  but, 
pending  suppression,  educational  work  drawing  attention 
to  possible  danger  from  flies  should  be  carried  on  among 
mothers  by  the  infant  hygiene  nurse. 

8.  Unofficial  Infant  Welfare  Organizations.  —  These 
play  an  important  part.  Baby  day  camps,  day  nurseries, 
etc.,  are  commonly  conducted  by  private  philanthropy, 
but  should  be  under  the  tactful  surveillance  of  the  health 
officer  and  should  be  coordinated  with  the  other  baby- 
saving  agencies  of  the  community.  "Baby  farms,"  or 
places  where  babies  are  boarded  out,  should  be  subjected  to 
official  inspection  and  some  control,  through  licensing  or 
otherwise,  should  be  exerted  over  them.  Other  cooperat- 
ing agencies  are  the  diet  kitchens  and  the  like,  from  which 
mothers  as  well  as  babies  may  obtain  nourishment  in  the 
shape  of  milk,  eggs,  etc. 

^  Bureau  Publication  no.  3,  "  Baby-Saving  Campaigns,"  p.  15. 


33©  A  MANUAL   FOR   HEALTH  OFFICERS 

Cooperation  should  be  maintained  with  the  general 
hospitals,  l>'ing-in  hospitals  and  other  institutions,  and 
the  development  of  social  service  work  in  connection  with 
them  is  to  be  encouraged. 

We  assume  for  the  present  that  nurses  and  infant  wel- 
fare stations  are  under  the  control  of  the  health  authorities, 
but  as  a  matter  of  fact  these  are  very  frequently  maintained 
by  unofficial  organizations  (see  later). 

9.  Prenatal  Care.  —  The  figures,  already  quoted  under 
the  head  of  infant  mortality  rates,  which  show  that  the 
majority  of  deaths  of  very  young  infants,  as  well  as  many 
stillbirths,  are  due  to  prenatal  conditions  or  to  injury  or 
accident  at  birth  are  a  compelling  argument  for  the  pre- 
natal care  of  mothers  and  the  improvement  of  the  practice 
of  midwifery  and  obstetrics.  This  indirect  but  highly 
important  protection  of  the  child  through  the  care  of  the 
mother  has  been,  of  the  main  phases  of  infant  welfare  work, 
the  last  taken  up.  The  problem  is  attacked  by  getting 
information  of  pregnant  women  at  as  early  a  time  as  possible 
and  keeping  them  under  observation  and  instruction  by 
competent  visiting  nurses  until  the  time  of  delivery.  This 
work  has  now  been  taken  up  by  a  number  of  infant  welfare 
organizations.     For  example: 

The  New  York  Milk  Committee  has  carried  on  for  two  years  an 
extensive  campaign  of  prenatal  instruction.  We  have  had  2003 
mothers  in  our  care.  They  are  visited  regularly  every  ten  days  to  two 
weeks  from  the  time  they  are  enrolled  until  the  baby  is  a  month  old. 
It  makes  no  difference  whether  the  mother  will  be  confined  in  the  hos- 
pital, or  by  a  physician  or  midwife  in  her  home.  .  .  .  We  have  had 
2070  babies.  .  .  .  Our  rate  of  stillbirths  among  our  supervised  mothers 
has  been  25  per  cent  lower  than  for  the  Borough  of  Manhattan  during 
the  same  period.  Of  babies  who  were  born  alive,  there  have  been  25 
per  cent  less  deaths  during  the  first  month  than  for  the  same  period 
in  the  Borough  as  a  whole.  Of  our  mothers,  93  per  cent  of  all  those 
whose  babies  were  living  at  the  end  of  the  first  month  were  nursing 
them  entirely.  Only  three  and  a  fraction  per  cent  were  being  fed 
artificially.' 

'  Trans.  4th  Ann.  Meeting  Am.  Assn.  for  Study  and  Prevention  of 
Infant  Mortality,  19 13,  p.  183. 


criiLi)  iiY(;iENE  331 

Similar  results  arc  given  for  tlic  work  cjirricd  011  in  Bos- 
ton under  the  Women's  Municii)al  League,  wliicli  states 
that 

The  number  of  birLlis  in  the  city  in  1912  was  approximately  19,000, 
and  the  percentage  of  stillbirths  in  that  year  was  39.3  per  thousand 
Hving  births.  Had  our  percentage  of  stillbirths  [18.6  per  thousand] 
obtained  throughout  the  whole  city  393  babies  would  have  been  born 
alive  whose  lives,  as  it  was,  were  extinguished  before  they  saw  the  light 
of  day.^ 

While  this  class  of  work  has  hitherto  been  carried  on 
entirely  by  unofficial  organizations,  it  is  closely  related  to 
the  instructive  work  of  the  infant  welfare  nurse  and  might 
well  be  added  to  it.^ 

10.  Control  of  Midwives.  —  The  ignorant,  ill-trained 
midwife  can  do  a  vast  amount  of  damage,  before  loirth,  at 
the  time  of  delivery,  and  in  the  aftercare  of  both  mother 
and  infant,  as  the  statistics  of  infant  mortality  and  deaths 
from  puerperal  causes  will  show. 

We  have  noted  above  the  large  proportion  of  deaths 
of  infants  due  to  factors  over  which  the  obstetrical  at- 
tendant has  control.  Of  the  practice  of  physicians  as 
obstetricians  we  say  nothing  here  except  that  it  should 
be  adequately  controlled,  like  other  medical  practice,  by 
proper  state  authority,  for  the  incompetent  male  obstetri- 
cian is  a  factor  to  be  considered.  As  to  the  practice  of  mid- 
wifery, it  should  be  subjected  to  strict  supervision  by  the 
state  in  the  same  manner  as  general  medical  practice ;  such 
supervision  should  require  adequate  training  as  a  prereq- 
uisite for  a  license,  and  there  should  be  courses  for  mid- 
wives  in  connection  with  hospitals  and  medical  inspection 

^  Trans.  4th  Ann.  Meeting  Am.  Assn.  for  Study  and  Prevention  oj 
Infant  Mortality,  1913,  p.  188. 

-  See  Schwarz,  "  PrenatalCare,"  Trans,  just  quoted,  p.  174,  and 
other  discussions  in  the  vols,  of  Trans,  of  tlie  Am.  Assn.  for  Study  and 
Prevention  of  Inf.  Mart.  For  an  account  of  the  details  of  prenatal 
care  see  the  valuable  pamphlet  on  "  Prenatal  Care,"  by  Mrs.  Max 
West,  Bureau  Publication  no.  4,  Children's  Bureau,  U.  S.  Dept.  of 
Labor,  1913. 


332  A  MANUAL  FOR   HEALTH  OFFICERS 

of  the  work  of  licensed  midwives  from  time  to  time.  The 
midwife  is  probably  too  deeply  rooted  in  social  and  eco- 
nomic conditions  to  be  eliminated  entirely,  as  has  been 
suggested,  but  may  l>e  made  the  best  of  through  an  offi- 
cial control  which  is  feasible  as  well  as  necessary.  The 
competent  midwife  is  capable  of  handling  a  normal  birth 
properly,  while  she  should  be  required  to  call  in  a  phy- 
sician if  abnormal  symptoms  present  themselves.  In  many 
communities  a  large  proportion  of  the  births  are  attended 
by  midwives  who  also  give  nursing  care,  etc.,  at  a  very 
low  cost,  and  to  attempt  to  deprive  the  poorer  population 
of  this  midwife  service,  which  it  appears  may  be  made  as 
safe  as  the  corresponding  order  of  medical  service,  would 
be  inadvisable.  At  present  it  is  lamentable  that  "some 
states  especially  exempt  midwives  from  all  provisions  of 
medical  practice  acts,  and  insist  that  they  can  practice 
without  license  and  control,"  and  that  "not  one  single 
state  in  the  Union  has  control  over  schools  of  midwifery 
in  regard  to  the  character  of  instruction  and  the  require- 
ments for  admission."  A  simple  and  effective  means  of 
eliminating  the  incompetent  midwife  "consists  in  getting 
the  same  kind  of  state  control  over  schools  of  midwifery 
and  the  admission  of  midwives  to  practice  as  is  exercised 
over  medical  schools  and  the  admission  to  medical  prac- 
tice."^ Attempts  at  local  control  may  have  some  effect 
but  must  necessarily  be  incomplete. 

It  has  also  been  suggested  that  a  special  class  of  trained 
nurses  might  be  licensed  to  act  as  midwives  and  gradually 
supplant  the  latter. 

II.  Use  of  Printed  Matter.  —  Many  health  departments 
issue  leaflets  and  the  like  for  the  instruction  of  mothers. 
Such  matter  is,  however,  of  no  use  with  the  ignorant  classes 
and  in  any  case  is  of  value  only  as  supplementary  to  oral 
instruction  and  demonstration. 

1  Schwarz,  paper  quoted  above.  Cf.  Van  Blarcom,  "  Midwives  in 
America,"  Am.  Jour.  Pub.  Health,  1914,  vol.  IV,  no.  3,  p.  197. 


cniM)  nY(;iKMK  333 

There  arc  many  factors  in  the  infant  welfare  problem 
which  cannot  be  extensively  consiflered  here.  For  ex- 
ample, there  is  the  effect  of  the  working  of  mothers  in 
factories  before  and  after  child-birth.  A  speaker  at  the 
XV  International  Congress  on  Hygiene  and  Demography' 
presented  figures  showing  that  in  factory  towns  in  Stafford- 
shire County,  England,  the  babies  of  mothers  at  home 
showed  an  annual  death  rate  per  thousand  births  of  146, 
while  the  rate  for  babies  of  mothers  in  factories  or  away 
from  home  during  the  day  was  201.  The  Medical  Ofificer 
of  Health  of  Birmingham,  going  into  the  question  in  a  very 
poor  working  class  population  of  his  own  district,  concludes 
that  "in  the  special  area  under  review  there  appears  to  be 
no  doubt  about  the  prejudicial  influence  of  employment  of 
pregnant  and  nursing  mothers  in  factories,  both  on  their 
infants  and  on  themselves";  but  adds  that  "poverty  has, 
however,  a  much  more  deleterious  influence;  and  if  by 
employment  poverty  can  be  removed  or  lessened,  such 
employment  is  the  lesser  by  far  of  two  evils.  "^  This  is  a 
matter  which  cannot  be  directly  dealt  with  by  health 
authorities,  but  relief  can  be  given  in  some  cases  through 
charitable  aid  which  enables  the  mother  temporarily  to 
discontinue  factory  employment,  wholly  or  in  part.  One 
of  the  evil  effects  of  such  employment  is  that  the  infant  is 
frequently  placed  on  the  bottle  and  left  at  home  in  charge 
of  some  incompetent  person. 

ORGANIZATION   OF   INFANT   HYGIENE  WORK 

Most  infant  welfare  work,  aside  from  the  super^•ision  of 
milk  supplies,  has  thus  far  been  maintained  by  unofificial 
organizations.  There  is  no  doubt,  however,  that  the  time 
is  ripe,  and  the  need  urgent,  that  health  departments  in 
all  communities,  small  and  large,  come  to  the  fore  and 
assume  their  proper  responsibilities  in  this  most  important 

^  Reid,  vol.  Ill,  pt.  II,  of  the  Transactions  of  the  Congress,  p.  943. 
^  Robertson,  ibid.,  p.  952. 


334  A  MANUAL   FOR   HEALTH   OFFICERS 

public  lu-alili  field;  that  thc>-  initiate  work  where  there  is 
now  none;  and  coiirdinate  and  complete  the  scheme  of 
work  where  |ihilanthroj)ic  organizations  are  already  at 
work.  The  health  authorities  alone  ha\'e  the  power  to 
compel  registration  of  births,  to  send  out  nurses  as  official 
inspectors,  to  supervise  milk  supplies  and  to  expend  public 
funds  in  the  establishment  of  infant  welfare  stations. 
Hence  leadership  and  efficiency  both  depend  upon  the 
department  of  health. 

The  plan  of  organization  and  operation  may  be  somewhat 
as  follows  (adapted  to  local  conditions) : 

1.  Make  a  brief  statistical  survey  of  the  infant  mortality 
situation  and  obtain  the  funds,  public  or  private,  necessary. 

2.  Studying  the  situation  more  in  detail  and  determin- 
ing in  what  districts  the  greatest  mortalities  occur,  divide 
the  community  into  districts  according  to  the  amount  of 
infant  mortality,  taking  into  account  also  the  character 
of  the  population  and  convenience  of  nurse  in  getting  about 
district.     Of  course  small  communities  need  no  districting. 

3.  In  each  district,  at  as  convenient  a  point  as  possible, 
arrange  for  an  infajit  ivelfare  station  to  serve  as  an  office 
for  the  nurse  of  the  district,  for  consultation  classes  and, 
if  milk  is  to  be  dispensed,  as  a  milk  station. 

4.  To  each  district  assign  one  infant  welfare  nurse,  to 
have  visiting  charge  of  the  infants  in  the  district,  to  assist 
at  consultations,  making  her  headquarters  at  the  station. 
The  number  of  babies  under  the  care  of  one  nurse  should 
not  be  greater  than  150.^  This  nurse  is  to  have  charge 
of  babies  whether  sick  or  well,  unless  they  are  so  ill  as  to 
require  hospital  care  or  to  be  placed  under  the  care  of  a 

'  The  New  York  Milk  Committee  (Special  Rpt.  on  Infant  Mortal- 
ity and  Milk  Stations,  1912,  p.  130)  states  that  "  one  nurse  for  every 
100  babies  is  the  limit  for  the  maximum  of  efficiency,  and  probably 
300  babies  the  limit  for  any  one  station."  These  estimates  would  of 
course  vary  with  local  conditions,  e.g.,  density  of  population,  location 
of  station,  etc.  In  a  less  densely  settled  district  the  latter  figure  would 
be  reduced,  the  former  to  a  less  extent  in  proportion. 


CHILD  HYGIENE  335 

special  district  nurse.  Thus  tlic  uursr  follows  the  cases 
both  at  lioinc-  and  at  the  station.  If  resources  warranl, 
prenatal   instruction  work   may  be  carried  on  by  nurses. 

5.  Obtain  the  regular  services  of  a  physician  for  each 
district,  who  will  conduct  at  the  station  the  weekly  consul- 
tation. Physicians  will  frequently  volunteer  their  services 
for  this  purpose.  If  the  same  physician  is  willing  to  serve 
in  more  than  one  district,  so  much  is  gained  in  uniformity 
of  methods,  an  advantage  on  account  of  the  moving  of 
families  from  one  district  to  another.  When  babies  become 
ill  they  may  be  referred  to  family  physician  or  to  a  clinic 
if  one  is  available  apart  from  the  consultation  station.  Of 
course  due  tact  must  be  exercised  in  relation  to  private 
physicians. 

6.  Where  various  divisions  of  the  work  (as  is  usually  the 
case)  are  carried  on  by  unofficial  organizations  there  should 
be  a  central  directing  committee,  to  determine  questions 
of  principle  rather  than  details,  composed  of  delegates 
from  the  various  organizations  involved.  The  health 
officer  may  act  as  executive  officer  of  this  committee,  pre- 
paring propositions  for  its  consideration  and  working  out 
the  relations  between  various  parts  of  the  work,  thus 
practically  guiding  its  policies  without  necessarily  having 
direct  control. 

7.  Modifications  of  this  plan  according  to  local  condi- 
tions will  suggest  themselves.  In  small  cities  where  there 
are  several  districts  it  may,  for  example,  be  most  convenient 
to  have  all  modification  of  milk  done  at  a  specialized  dis- 
pensary in  one  district.  In  Cleveland,  Ohio,  a  district  plan 
is  in  operation,  but  all  sick  babies  are  sent  to  a  Central 
Dispensary  of  the  Babies'  Hospital.  There  also  is  found 
an  excellent  example  of  cooperation  between  the  health 
department  and  unofficial  organizations.^ 

8.  Dispensation  of  milk  should  be  carried  on  in  such  a 

^  Report  of  the  Babies'  Dispensary  and  Hospital,  Cleveland,  Ohio, 
for  year  ending  Sept.  30,  1912,  p.  19  ft". 


336  A  MANUAL   FOR   HEALTH  OFFICERS 

manner  as  not  to  encourage  bottle-feeding,  but  simply 
with  the  object  of  supplying  a  high  grade  of  milk,  in  those 
cases  where  needed,  at  a  reasonable  cost.  This  milk  should 
be  given  out  in  the  whole  form  and  the  mothers  taught 
home  modification,  except  in  cases  of  incapacity  or  illness  of 
the  mother  which  make  it  necessary  to  modify  at  the  milk 
station.^  Where  the  health  department  is  able  to  specify 
certain  milk  supplies  on  the  market  as  being  of  sufficiently 
high  and  reliable  grade  to  meet  approbation  for  infant 
feeding  (and  this  of  course  should  be  the  case),  such  sup- 
plies, delivered  at  the  homes  in  the  usual  manner,  may 
take  the  place  of  dispensary  milk.  Where  the  grading  of 
market  milk  is  carried  out  this  may  readily  be  the  case. 
It  must  always  be  remembered  that  the  functions  of  over- 
sight and  instruction,  beginning  in  the  prenatal  period  and 
extending  through  early  infancy,  and  not  merely  milk 
distribution,  are  the  chief  objects  of  the  infant  welfare 
station. 

The  following  quotation  describes  very  specifically  what 
can  be  done  in  the  way  of  organization  in  small  towns  and 
cities. 

If  there  is  one  hospital,  one  charitable  society  and  one  or  more 
churches  in  a  town  doing  social  work,  we  immediately  have  the  nucleus 
for  a  small  babies'  welfare  association,  and  we  believe  that  the  lesson  in 
the  possibilities  of  cooperation  under  the  greatest  of  difficulties,  learned 
in  New  York  City,  can  be  applied  in  modified  form  in  smaller  commu- 
nities much  more  easily.  Stamford,  Connecticut,  for  instance,  a  city  of 
15,000  inhabitants,  has  one  hospital,  a  visiting  nurse's  association  and 
an  association  of  charities,  which  includes  a  number  of  churches,  lodges 
and  other  societies.  From  these  few  elements  they  have  decided  that 
they  can  profitably  organize  a  babies'  welfare  association  something 
along  the  line  of  that  tried  successfully  in  New  York  City. 

Any  village  or  city  of  over  5000  inhabitants  might  profitably  estab- 
lish a  milk  station,  or,  even  better,  a  child  welfare  center  in  which 
educational  work  alone  is  conducted,  if  the  general  milk  supply  of  the 
community  is  of  a  high  enough  grade,  and  does  not  merit  the  special 

*  See  remarks  on  p.  310  f. 


CHILI)  iiY(;iKNi';  337 

dispensing  of  pure  milk.  As  an  cxani[)l(;,  the  (•x])crU:nm  of  Englcwood, 
N.  J.,  might  be  citcfl.  This  town  has  only  about  lo/xx)  inhabitants, 
but  as  a  result  of  an  influx  of  a  foreign  element  the  infant  mortality  rate 
became  very  high.  A  small  cottage  was  rented  and  a  dispensary  and 
baby  shelter  established  where  the  nurses  in  attendance  gave  instruc- 
tions to  mothers  on  the  care  of  their  babies.  The  doctor  in  charge 
treated  all  diarrhoeal  cases  and  two  or  three  beds  were  provided  where 
babies  could  be  kept  temporarily  in  case  their  mothers  were  sick. 
At  the  same  time  pure  milk  was  sold,  at  a  moderate  cost,  to  the  mothers 
who  needed  to  give  their  babies  artificial  feeding.  As  a  result  the 
Englewood  infant  death  rate  was  effectively  cut  down.  It  now  has 
one  of  the  lowest  death  rates  of  any  community  of  its  size  in  the  State 
of  New  Jersey. 

In  smaller  villages  where  a  station  could  not  be  run  to  advantage, 
and  where  milk  dispensing  is  not  necessary,  educational  work  can  be  and 
is  done,  successfully,  by  a  single  visiting  nurse.  Even  in  hamlets  and 
rural  communities  a  church  society  can  provide  a  fund  from  which 
a  local  nurse  can  be  hired  temporarily,  whenever  there  is  a  family  in 
need  of  such  work. 

The  same  suggestions  can  be  made  regarding  prenatal  work  as  re- 
garding milk  station  work  in  smaller  communities.  We  believe  the 
work  can  be  carried  on  in  larger  cities,  by  districts,  just  as  it  is  carried 
on  in  New  York  Citj'.  In  smaller  communities  any  visiting  nurse  or 
organization  employing  visiting  nurses  can  profitably  take  up  this 
effective  and  not  costly  effort  to  save  infant  lives  and  reduce  not  only 
mortality  but  morbidity.^ 

As  the  result  of  careful  study  of  the  needs  of  the  city 
of  Newark,  N.  J.,  and  the  work  begun  there  under  un- 
ofificial  organization,  the  following  conclusions  of  general 
interest  were  reached: 

Infant  consultation  stations  are  less  expensive  and  more  efficient 
than  milk  depots. 

All  mothers  can  be  taught  to  prepare  milk  for  their  infants  at  home. 

^  Dr.  Pisek,  Medical  Director,  New  York  Milk  Committee,  "  The 
Health  Officer's  Place  in  the  Campaign  for  the  Reduction  of  Infant 
Mortality,"  in  Special  Bulletin  of  N.  Y.  State  Dept.  of  Health  on  Infant 
Welfare  Conference,  June,  1913.  See  also  other  papers  in  same,  esp. 
Clarke,  "  Infant  Welfare  Work  in  Small  Cities."  This  bulletin  and 
the  one  on  Infant  Welfare  Stations  in  New  York  State,  also  issued  by 
the  New  York  State  Dept.  of  Health,  contain  a  great  deal  of  value  to 
the  health  officer  concerned  in  the  establishment  of  infant  welfare  work. 


338  A   MANUAL   I'OR   HEALTH  OrFICERS 

Pure  milk  can  he  olitained  for  babies  at  a  price  within  reach  of  all. 

The  mortality  of  infants  under  one  year  of  age  is  exceedingly  high 
in  all  institutions. 

Infants  deprived  of  mother's  care  should  be  placed  out  in  properly 
supervised  private  homes. 

Ignorance  is  the  greatest  single  factor  in  infant  mortality. 

Education  of  mothers  and  the  supervision  of  babies  cause  the  great- 
est reduction  of  infant  mortality. 

The  prompt  and  accurate  notification  of  births  is  necessary  to  enable 
us  to  prevent  the  great  mortality  of  the  first  week  of  life.^ 

Midwives  can  become  a  great  force  in  the  education  of  our  foreign- 
born  mothers  in  infant  hygiene  through  active  and  careful  supervision. 

The  reduction  of  infant  mortality  can  best  be  accomplished  by  the 
establishment  of  a  municipal  department  of  child  hygiene.^ 

In  some  communities  it  has  been  found  feasible  to  com- 
bine the  instructive  nursing  work  with  other  similar  work. 
Thus  in  a  number  of  places  (e.g.,  New  York  City,  Syracuse, 
N.  Y.,  et  al.)  the  school  nurses  have  done  infant  welfare 
work  during  the  summer  months.  In  other  sinall  towns 
(e.g.,  Montclair,  N.  J.)  one  nurse  has  been  employed  for 
both  tuberculosis  and  infant  welfare  work.  Such  exped- 
ients are  useful  where  full-time  nurses  cannot  be  secured. 

Summer  Campaigns  or  All-the-Year-Round  Work?  — 
In  most  places  where  infant  hygiene  work  has  been  taken 
up  it  had  its  inception  with  a  summer  campaign.  And  it 
is  true  that  the  summer  season  is  the  most  severe  on  infant 
life,  for  in  some  cities  one-third  to  almost  one-half  of  the 
whole  infant  mortality  occurs  in  the  third  quarter,  i.e., 
July  to  September  inclusive.  But  it  should  not  be  supposed 
that  little  or  no  work  is  needed  during  the  winter  months. 
During  those  months  there  occur  many  deaths  from  pre- 
ventable causes;  the  deaths  from  diseases  of  the  respiratory 
system  are  numerous,  while  the  steady  succession  of  deaths 

1  Prenatal  work  may  also  be  undertaken  with  this  object.  —  J.  S.  M. 

-  Rpt.  on  "  The  Work  of  the  Public  Welfare  Committee  of  Essex 
County  [N.  J.]  for  the  Reduction  of  Infant  Mortality,"  by  Dr.  Julius 
Levy,  1912.  Issued  by  the  Committee  at  665  Broad  Street,  Newark, 
N.J. 


ciiii.i)  iiy(;[i;nI';  339 

due  to  prenatal  causes  and  improper  care  at  and  just  after 
birth  goes  on  steadily  irrespective  of  season.  Moreover, 
the  educational  character  of  the  work  recjuires  that  it  be 
carried  on  continuously  in  (jrder  to  take  root  and  gain  con- 
tinued confidence.  Thus,  too,  skill  and  attachment  on 
the  part  of  nurses  is  obtained.  Hence,  while  summer 
campaigns  alone  accomplish  an  immense  amount  of  good, 
an  adequate  plan  involves  nurses  and  consultation  stations 
steadily  at  work  all  the  year  round. 

Costs  and  Results.  —  The  costs  of  infant  welfare  work 
will  depend  somewhat  on  local  conditions.  The  salary  of 
a  trained  nurse  is  usually  $65  or  $75  a  month.  Rooms 
suitable  for  welfare  stations  are  obtainable  in  the  poor 
districts  where  they  are  usually  located,  at  a  low  rental. 
Rooms  in  public  schools,  settlements  and  the  like  solve 
the  rent  problem  completely.  The  equipment  needed  for 
an  ordinary  station  is  comparatively  inexpensive,  and  re- 
quires little  in  the  way  of  renewal.  Where  a  special  supply 
of  milk  is  desired  it  can  usually  be  obtained,  by  arrange- 
ment, of  proper  quality  and  at  a  price  not  exceeding  that 
of  ordinary  market  milk.  This  milk  may  be  dispensed 
from  the  station  or  arrangement  may  be  made  whereby 
the  dealer  delivers  to  the  homes.  This  part  of  the  work 
need  not  involve  charity,  for  in  almost  all  cases  the  families 
should  be  able  to  pay  the  full  cost  price. 

The  average  total  maintenance  cost  per  baby,  per  month, 
is  given  for  certain  stations  in  New  York  State  which  were 
operated  during  the  summer,  as  $1.04,  including  the  equip- 
ment in  the  majority  of  cases. ^ 

As  for  results,  it  must  be  noted  that  the  w^ork  is  prima- 
rily educational,  and  since  education  is  a  gradual  process, 
immediately  conspicuous  results  in  the  general  infant  mor- 
tality rate  should  not  necessarily  be  expected.  A  detailed 
study  of  the  work  in  the  districts  where  it  has  been  carried 
on  should  disclose  some  results  even  during  the  first  season. 
1  See  p.  326. 


340  A   MANUAL   FOR   HEALTH  OFFICERS 

Dr.  Josephine  S.  Baker,  of  the  New  York  City  Division 
of  Child  Hygiene,  at  the  New  York  State  Conference  al- 
ready mentioned,  stated  that  "for  the  four  years  previous 
to  1908  in  New  York  City  the  death  rate  of  babies  under 
one  year  of  age  ranged  from  about  160  to  164  per  thousand; 
in  the  four  years  since  1908  that  death  rate  has  been  reduced 
from  160  to  105  per  thousand."  This  as  the  result  of 
infant  hygiene  work  carried  on  by  the  New  York  Milk 
Committee  and  other  unofficial  organizations  in  coopera- 
tion with  the  Division  of  Child  Hygiene  of  the  Department 
of  Health.  The  New  York  Milk  Committee  has  made  a 
special  and  detailed  study  of  the  infant  welfare  work  carried 
on  in  the  ten  largest  cities  of  the  United  States,  as  the  result 
of  which  the  following  conclusions,  all  applicable  to  work 
in  small  communities  as  well,  are  given: 

1.  The  reduction  of  infant  mortality  in  191 1  in  the  cities  studied 
was  ver>'  marked,  especially  during  the  summer  months.  During  the 
first  part  of  the  summer  meteorological  conditions  were  not  favorable  to 
a  low  mortality. 

2.  This  reduction  was  not  due  to  chance,  but  bears  a  close  relation 
to  the  activity  of  the  campaign  for  the  reduction  of  infant  mortality. 
The  difference  between  cities  in  infant  mortality  rates  is  probably  more 
a  matter  of  public  conscience  and  quality  of  official  endeavor,  thaja 
weather  and  character  of  population. 

3.  The  full  effects  of  any  campaign  will  not  be  seen  immediately. 
Dr.  Robertson,  Health  Officer  of  Birmingham,  England,  said  at  the 
conference  at  Caxton  Hall  that  he  would  be  satisfied  if  he  got  results 
after  ten  years'  work. 

4.  In  the  education  of  the  mother  in  the  care  of  herself  and  her 
baby  we  have  the  strongest  weapon  for  fighting  infant  mortality. 

5.  The  results  in  the  milk  stations,  as  shown  by  the  detailed  histories 
of  3182  babies,  have  proved  the  usefulness  of  the  milk  station  in  the  re- 
duction of  infant  mortality.  It  is  one  of  the  most  efficient  forces  in  the 
educational  prevention  of  sickness  and  deaths  among  babies. 

6.  Its  field  of  usefulness  can  be  very  greatly  extended  into  other 
branches  of  infant  and  child  welfare,  such  as  prenatal  work;  the  care 
of  children  under  school  age;  follow-up  work  in  inspection  of  school- 
children; supervision  of  boarded-out  babies  and  midwives,  etc.  Sta- 
tions should  be  maintained  all  the  year  around  in  order  to  make  their 
value  cumulative. 


CHILD   HYGIENE  341 

9.  Compulsory  attendance  under  penally  of  stopping  milk  supi^ly 
should  be  insisted  on. 

10.  When  efficiently  manajj;ed,  the  milk  station  is  an  economical 
means  of  forwarding  the  movement  for  infant  welfare. 

11.  The  results  of  the  methods  employed  at  the  Committee's  milk 
stations  prove  conclusively  the  entire  feasibility  of  teaching  home  mod- 
ification of  milk,  thus  not  only  doing  away  with  expensive  laboratory 
plants,  but  making  the  mother  eventually  independent  of  the  station. 

12.  The  milk  station  can  and  should  be  a  valuable  means  of  en- 
couraging and  making  possible  maternal  nursing.  It  need  not  be  an 
encouragement  to  artificial  feeding. 

13.  Private  agencies  are  warranted  in  initiating  milk  station  work, 
but  their  program  should  provide  for  having  the  municipality  assume 
charge  as  soon  as  practical.  The  activities  which  are  possible  for  the 
stations  are  proper  functions  for  the  municipality.  Close  cooperation 
between  health  authorities  and  private  organizations  is  entirely  feasible 
and  necessary. 

14.  The  education  of  the  "  little  mothers  "  in  the  care  of  the  baby 
will  insure  not  only  immediate  results,  but  will  pave  the  way  for  better 
motherhood. 1 

Other  examples  may  readily  be  found  to  illustrate  the 
results  of  infant  hygiene  work  carried  on  in  small  cities. 
In  Orange,  N.  J.,  the  dispensing  of  milk  had  been  carried 
on  for  some  years  by  a  private  organization.  In  191 1 
another  organization  raised  additional  funds  and  placed 
in  the  field,  working  as  a  special  inspector  under  the  super- 
vision of  the  Health  Officer,  an  infant  welfare  nurse.  In 
the  Report  of  the  Health  Officer  for  1912,  the  first  full  year 
that  the  nurse  was  at  work  in  cooperation  with  the  Health 
Department  and  unofficial  organizations,  the  following 
remarks  appear: 

The  low  record  of  mortality  obtained  among  the  cases  under  super- 
vision of  the  nurse  is  a  gratifying  result  which  demonstrates  the  value 
of  the  preventive  measures  adopted.     Eleven  of  these  cases  died  [de- 

1  Special  Rpt.  "  Infant  Mortality  and  Milk  Stations,"  1912,  p.  129. 
Cf.  statistical  survey  of  results  of  consultation  stations  and  milk  dis- 
tribution in  various  French  and  American  cities  by  Freeman,  "  Infant 
Milk  Depots,"  Proceedings  Conf.  on  Inf.  Hyg.,  Rpt.  Phila.  Milk  Show, 
1912,  p.  191. 


342  A  MANUAL   FOR   HEALTH  OFFICERS 

tailsset  forth  in  table].  Cases  Nos.  3,  4  and  11  died  from  non-pre- 
ventable causes.  ...  In  most  of  the  other  cases  only  a  small  number 
of  visits  had  been  paid;  for  instance,  in  two  cases  there  had  been  but 
one  visit,  and  in  two  others  two  \isits.  In  several  instances  there  was 
little  cooperation  on  the  part  of  the  mother. 

In  order,  however,  to  make  the  most  conservative  possible  calcula- 
tion, all  of  the  above  eleven  deaths  are  taken  as  the  mortality  among 
the  450  cases  under  supervision.  This  gives  a  percentage  of  2.4,  which, 
however,  should  be  corrected  for  the  fact  that  the  cases  were  not  all 
under  observation  the  whole  year,  but  only  for  an  average  of  I2i  days. 
The  corrected  death  rate  would  then  be  7.4  per  cent  per  annum.  This 
rate,  if  compared  with  the  infant  mortality  rate  for  the  city  for  1910  and 
other  years  preceding  inception  of  the  nurse's  work  (average  about 
11.5  deaths  under  one  j-ear  per  thousand  births),  shows  .  .  .  the 
marked  reduction  which  the  work  of  the  nurse  effects.  Nearly  the 
same  reduced  death  rate  (6.8  per  cent)  had  previously  resulted  among 
the  infants  under  supervision  in  191 1.  .  .  .  The  benefits  .  .  .  through 
the  saving  in  vitality  and  the  prevention  of  disease  and  weakliness,  both 
in  babyhood  and  in  later  life,  though  not  susceptible  of  demonstration 
by  figures,  are  also  obviously  of  immense  importance. 

It  is  to  be  noted  that  the  above  results  were  obtained 
in  the  first  two  years  of  the  work  and  with  incomplete 
organization.  With  improved  organization  and  the  cumu- 
lative effect  of  education  of  mothers  and  "little  mothers" 
the  estimate,  based  on  statistics,  that  at  least  50  per  cent 
of  the  deaths  which  occur  in  the  first  year  of  life  can  be 
saved  by  infant  welfare  work,  will  doubtless  be  fully  borne 
out;  although  in  this  instance  it  must  be  remembered  that 
a  substantial  amount  of  infant  hygiene  work  was  already 
being  carried  on  by  a  diet  kitchen  and  other  organizations 
when  the  infant  welfare  nurse  began  her  work.  It  may  be 
a  source  of  encouragement  to  other  small  cities  to  know 
that  in  the  above  instance  the  municipal  council,  persuaded 
by  the  results  obtained  under  private  efforts,  appropriated 
to  the  health  department  a  sufficient  sum  to  carry  on  the 
entire  work  of  the  nurse  under  an  improved  system  of 
organization.  This  is  merely  an  example  of  what  may 
be  done  in  many  American  communities. 


CI  1 1  I.I)  i(Y(;ii;nI';  34;^ 

When  funds  for  Lhc  work  are  liniilcd,  as  is  very  frcfiiicntly 
the  case,  the  work  sliouUl  not  be  spread  out  "thin"  over 
an  excessively  hirge  number-  of  cases,  but  should  be  con- 
centrated so  as  to  get  results  which  may  be  used  as  a  basis 
for  obtaining  increased  financial  support.  The  natural 
limits  of  control  should  not  be  exceeded. 

In  calculating  statistical  results  and  making  comparisons 
with  annual  infant  mortality  rates  (deaths  under  one  year 
per  thousand  births),  the  rates  calculated  for  infants  under 
supervision  should  be  reduced  to  an  annual  basis  to  corre- 
spond, as  is  done  in  the  quotation  above;  otherwise  the 
comparison  is  fallacious  and  will  lead  to  erroneous  and 
extravagant  conclusions.  Thus,  if  the  average  duration 
of  supervision  of  cases  is  121  days,  or  Hd  of  a  year,  the 
death  rate  among  these  cases  should  be  multiplied  by  fir  to 
reduce  it  to  a  per  annum  rate.  Again,  when  the  infant 
mortality  rates  from  year  to  year  are  compared,  it  is  to  be 
remembered  that  improved  birth  registration,  by  increas- 
ing the  denominator  of  the  ratio,  tends  to  make  the  rate 
apparently  lower,  independently  of  actual  change  in  mor- 
tality. 

In  conclusion  we  revert  to  the  statement  quoted  at  the 
head  of  this  chapter,  that  child  —  especially  infant  — 
hygiene  work  is  a  requisite  function  of  every  well-organized 
health  department.  While  in  most  instances  such  work 
has  been  thus  far  initiated  and  its  value  demonstrated 
by  unofificial  organizations  before  being  assumed  by  public 
authorities,  the  time  has  now  come  for  those  authorities 
themselves  to  take  the  initiative  in  obtaining  funds  and 
organizing  the  work.  The  work  of  the  unofificial  organi- 
zations already  in  the  field  should  thus  be  coordinated, 
supplemented,  and,  so  far  as  advisable,  officially  adopted. 
In  this  development  the  idea  of  charity  will  be  more  and 
more  removed  from  the  main  phases  of  the  work  and  its 


344  A  MANUAL   FOR   HEALTH  OFFICERS 

influence  correspondingly  extended.  Thus  health  author- 
ities stand  in  infant  hygiene  work  just  where  they  stood 
in  relation  to  tuberculosis  work  a  few  years  back,  and  the 
assumption  of  the  former  by  them  should  be,  in  the  light  of 
advancing  knowledge,  even  more  rapid  than  that  of  the 
latter.  The  fact  that  success  in  notable  measure  has  been 
achieved  in  those  larger  cities  which  have  led  in  sanitary 
organization  is  the  impetus  for  the  extension  of  similar 
methods  to  the  smaller  cities  and  towns,  where  problems 
of  organization  are  simpler  —  nay,  even  to  the  most  rural 
communities,  where  the  need  is  nearly  if  not  wholly  as 
great. 

REFERENCES 

In  addition  to  the  references  given  in  the  text  the  following  may  be 
cited: 

Publications  of  the  Children's  Bureau,  U.  S.  Department  of  Labor, 
Washington,  which  may  be  obtained  regularly  on  application. 

Annual  Transactions  of  the  American  Association  for  Study  and 
Prevention  of  Infant  Mortality,  1910  and  subsequent  years.  (121 1 
Cathedral  Street,  Baltimore,  Md.)- 

Bull.  Am.  Acad.  Med.,  1910,  vol.  XI,  no.  6  ("  Infant  Mortality  "). 

Trans.  XV  International  Congress  on  Hygiene  and  Demography,  1912, 
vol.  Ill,  pt.  I. 

Rpt.  of  Philadelphia  Baby-Saving  Show,  1912.  (The  Child  Hygiene 
Association,  Real  Estate  Trust  Building,  Philadelphia.) 

McCleary,  "  Infantile  Mortality  and  Infants'  Milk  Depots,"  Lon- 
don, 1905. 

Newman,  "  Infant  Mortality:   A  Social  Problem,"  London,  1906. 

Holt,  "  The  Care  and  Feeding  of  Children." 

Kerr,  "  Data  Regarding  Operations  of  Infants'  Milk  Depots  in  the 
United  States  in  1910,"  Reprint  no.  64  from  Public  Health  Reports, 
1911. 


CHAPTER    III 

MILK  AND  OTHER  FOOD  SUPPLIES 

I.   MILK 

Milk  is  by  far  the  most  important  food  with  which  the 
health  official  has  to  deal.  On  the  one  hand  it  is  one  of  the 
most  valuable,  cheapest  and  most  extensively  used  foods, 
particularly  for  infants  and  young  children;  and  on  the 
other,  it  is  specially  subject  to  contamination  and  deteriora- 
tion. Again,  while  the  sanitary  regulation  of  milk  supplies 
demands  the  most  serious  attention,  there  are  also  economic 
problems  in  connection  with  milk  as  a  market  commodity 
which  are  closely  interrelated  with  those  of  a  hygienic 
character. 

GENERAL   REQUIREMENTS 

We  may  promise  the  following  requirements  for  a  safe 
and  satisfactory  milk  supply,  viz.,  it  must  be: 

1.  From  healthy  cows. 

2.  Drawn  and  handled  in  a  cleanly  manner. 

3.  Free  from  deleterious  bacterial  decomposition. 

4.  Unadulterated  and  of  a  sufficient  food  value. 

5.  Free  from  infection  from  human  or  animal  source. 

Of  these  requirements  the  last-named  is  the  most  impor- 
tant, but  depends  in  a  great  degree  upon  the  first  three.  We 
shall  take  up  these  requirements  in  detail  and  explain  just 
what  is  implied  by  each. 

I.  The  supply  must  be  obtained  from  healthy  cows.  — 
This  requirement  implies  freedom  of  cows  from  udder  dis- 
ease, from  at  least  clinically  detectable  tuberculosis,  and 

34S 


346  A  MANUAL   FOR   HEALTH  OFFICERS 

from  other  diseases  transmissible  from  animal  to  man.     All 
these  will  be  taken  up  presently  under  the  head  of  infection. 

2.  The  supply  must  be  drawn  and  handled  in  a  cleanly 
manner.  —  iVIilk  is  highly  susceptible  to  contamination  and 
has  the  peculiar  property  of  not  showing  the  dirt  which  it 
may  have  taken  up,  even  when  the  contamination  is  heavy. 
At  every  stage,  from  the  cow  to  the  ultimate  consumer, 
there  are  numerous  possibilities  of  contamination,  from  dirty 
cows  and  stables,  from  dirty  methods  of  milking  and  hand- 
ling, from  dirty  utensils  and  dirty  fingers.  At  the  stable 
a  great  deal  of  the  contamination  is  with  manure  (contain- 
ing the  colon  bacillus  and  other  bacteria  and  frequently  the 
bacillus  of  bovine  tuberculosis).  At  all  stages  the  contami- 
nation consists  in  miscellaneous  kinds  of  dirt  and  filth,  with 
the  constant  possibility  of  infection  by  communicable 
disease.  Contaminations  are  not  only  in  themselves  bad, 
but  they  are  the  starting  point  of  various  bacterial  fer- 
mentations which  tend  to  make  the  milk  an  unfit  and 
possibly  a  dangerous  food,  particularly  for  young  children. 

3.  The  supply  must  be  free  from  deleterious  bacterial 
decomposition.  —  Milk  kept  insufficiently  cold  or  too  long 
undergoes  decompositions  of  various  kinds  due  to  the 
action  of  the  bacteria  present  upon  the  organic  food  sub- 
stances of  the  milk.  Since  it  is  physically  impossible,  even 
with  the  greatest  precautions,  to  obtain  and  keep  a  bacteria- 
free  milk,  the  only  safeguard  against  decomposition  is  to 
keep  the  milk  at  a  low  temperature  (below  50°  F.  for  market 
milk)  and  to  consume  it  as  soon  as  practicable  after  pro- 
duction. These  decompositions  are  either  acid  or  alkaline 
in  character.  The  former  lead  to  the  ordinary  souring  of 
milk,  are  more  common,  take  place  quickly  when  milk  is 
allowed  to  remain  warm  —  i.e.,  at  70°  F.,  or  above  —  and 
are  the  less  dangerous  variety.  This  is  the  variety  of  fer- 
mentation made  use  of  for  obtaining  sour  milk  for  special 
purposes,  in  which  case,  however,  the  milk  should  be 
specially  prepared  and  inoculated  with  a  known  organism. 


MII.K    AND   ()'l'lll';k    l'(K)l)    Sdl'I'lJKS  ..547 

Tlie  alkaline  dccomposilions  usually  lake  place  at  lf)vver 
temperatures  and  lead  to  i)Utrefaelions  which  are  exceed- 
ingly dangeroUvS.  Tliis  is  the  case  with  milk  which  has 
been  pasteurized  at  a  high  temperature  so  as  to  kill  off  the 
lactic  acid  bacilli  (acid  fermenters)  and  which  is  afterwards 
allowed  to  decompose  through  lack  of  sufficient  refrigera- 
tion. 

Tn  the  prevention  of  bacterial  decomposition  the  maxim 
that  milk  should  be  clean,  cold  and  fresh  covers  the  essential 
requirements.  It  must  be  noted,  however,  that  a  certain 
limited  number  of  bacteria  may  be  present  without  pro- 
ducing any  deleterious  fermentation,  provided  the  above 
conditions  are  practically  observed.  But  a  milk  that  is 
either  dirty,  or  warm,  or  stale  must  always  be  looked  upon 
as  a  dangerous  product. 

Contaminated  and  decomposed  milk  has,  as  we  saw  in 
the  last  chapter,  a  special  bearing  on  infant  mortality.  The 
following  passage  sums  up  the  common  opinion  of  authori- 
ties. 

There  is  no  specific  germ  that  causes  malnutrition  and  the  gastro- 
intestinal troubles  of  infants.  It  is  the  general  observation  that  the 
presence  of  streptococci  and  colon  bacilli  in  milk  does  augment  these 
disorders.  Excessive  numbers  in  milk  of  any  germ,  even  those  at  times 
considered  to  be  harmless,  has  been  found  also  to  be  productive  of  these 
troubles.  The  presence  of  colon  bacilli  is  the  source  of  great  danger  to 
children. 

The  effects  of  contaminated  milk  have  been  shown  by  the  prevalence 
of  diarrhoeal  diseases  and  the  occurrence  of  numerous  cases  of  mal- 
nutrition amongst  infants  raised  upon  cow's  milk.  One  has  but  to 
observe  the  mortality  tables  during  the  summer  months  and  compare 
the  bacteriological  reports  of  milk  ordinarily  used  for  infant  feeding  to  be 
convinced  of  the  direful  influence  of  such  milk.' 

A  striking  example  of  the  benefits  of  milk  improvetnent 
where  the  subjects  were  adults  is  given  in  the  annual  report 
for  1912  of  Dr.  A.  D.  Melvin,  Chief  of  the  Federal  Bureau 
of  Animal  Industry,  who  states  that  through  improvement 

^  Magruder,  pamphlet  cited  on  p.  397. 


348  A  MANUAL   1"0R  IIKALTH  OFFICERS 

of  the  milk  supply  of  the  U.  S.  Naval  Academy  at  Annapolis, 
Md.,  gastro-intestinal  disorders  among  the  midshipmen 
were  reduced  from  133  to  25  per  month.  If  this  is  the 
phenomenon  observed  among  healthy  adults,  what  must  be 
the  effect  of  bacteria-laden  milk  supplies  on  the  delicate 
organisms  of  infants,  young  children  and  invalids! 

Since  cow's  milk  must  be  used  to  a  considerable  extent 
in  the  artificial  feeding  of  infants,  in  whole  or  in  part,  and 
to  a  very  large  extent  among  all  children  from  one  year  up, 
the  magnitude  of  this  phase  of  the  milk  problem  is  evident. 

4.  The  supply  must  be  unadulterated  and  of  sufficient 
food  value.  —  Since  milk  is  of  a  naturally  variable  com- 
position and  the  consumer  has  no  exact  way  of  knowing 
what  its  food  value  is,  standards  should  be  set  for  per- 
centages of  fats  and  total  solids.  Such  standards  must  be 
adapted  to  the  percentages  found  in  the  milks  of  different 
kinds  and  grades  of  cattle,  their  principal  object  being  the 
protection  of  the  consumer  against  watering,  skimming 
and  other  frauds.  This  is  the  class  of  food  laws  which  pro- 
tect against  fraud  perhaps  even  more  than  against  damage 
to  health.  However,  the  richness  of  milk  has  a  distinctly 
important  public  health  bearing,  particularly  when  there 
is  question  of  modifying  milk  and  feeding  infants.  The 
addition  of  preservatives,  in  themselves  deleterious  and 
also  highly  objectionable  as  covering  up  —  but  not  removing 
—  decomposition,  falls  under  the  same  class  of  prohibition. 

5.  The  supply  must  be  free  from  infection  from  human 
or  animal  source.  —  Milk  not  only  readily  takes  up  infection 
in  the  course  of  production  and  handling  but  also  may  act 
as  a  culture  medium  in  which  pathogenic  organisms  actually 
multiply.  Hence  we  find  on  record  hundreds  of  epidemics 
which  have  been  traced  to  milk  supplies,  in  addition  to 
which  there  are  thousands  of  cases,  occurring  sporadically 
or  in  epidemics,  which  have  escaped  such  recording.  This 
aspect  of  the  milk  problem  overshadows  the  others  in  im- 
portance.    Now  that  milk  is  frequently  handled  on  a  large 


MILK   AND    O'lniOk    I'OOI)    SUI'TUKS  349 

scale,  the  damage  that  may  Ije  done  by  a  single  infection  of 
a  milk  supi^ly  is  enormous.  Several  years  ago  one  of  our 
large  cities  experienced  an  epidemic  of  looo  cases  of  typlK>id 
fever  from  a  single  source  of  infected  raw  milk.  Other 
cities  and  towns,  small  as  well  as  large,  have  from  time  to 
time  suffered  more  or  less  severe  milk-borne  epidemics  of 
various  diseases;  under  present  conditions  none  are  im- 
mune. The  presence  of  carriers  and  missed  cases  among 
employees  connected  with  milk  supplies  very  seriously 
aggravates  the  danger. 

Diseases  of  Human  Origin.  —  The  principal  diseases 
of  human  origin  of  which  milk  may  act  as  a  vehicle  are: 
typhoid  fever  and  other  intestinal  diseases,  diphtheria,  scarlet 
fever  and  septic  sore  throat}  We  shall  not  here  discuss  this 
important  subject  further,  but  refer  the  reader  to  the  sec- 
tion on  epidemiology  (pp.  266-92)  where  further  examples 
and  details  are  given.  In  the  present  section  the  preven- 
tion rather  than  the  occurrence  and  characteristics  of  milk- 
borne  epidemics  will  be  considered. 

Diseases  of  Animal  Origin.  —  The  principal  milk- 
borne  disease  of  animal  origin  is  bovine  tuhercidosis.  It  is 
now  well  established  through  extensive  researches  that 
although  the  bovine  tubercle  bacillus  is  apparently  distinct 
from  the  human  type,  bovine  tuberculosis  may  be,  and  in  a 
certain  proportion  of  cases  is,  communicated  to  man  through 
milk.  Tuberculous  cattle  excrete  the  bacilli  in  great  num- 
bers in  the  feces,  and  particles  of  manure  getting  into  the 
milk  at  time  of  milking  infect  it;  this  is  the  commonest 
source  of  tubercle  bacilli  in  milk.  This  is  true  even  with 
cattle  which  give  no  physical  signs  of  the  disease;  in  these 
cases  the  diagnosis  can  only  be  made  by  means  of  the 
tuberculin  test.  (For  discussion  of  the  test  and  of  the 
relative  numbers  of  dairy  cows  which  are  found  to  react  to 
it,  see  following  section.) 

1  In  some  epidemics  septic  sore  throat  has  been  attributed  to  udder 
disease  in  cows  and  in  others  to  human  carrier  cases. 


35°  A  MANUAL  FOR  HEALTH  OFFICERS 

"As  to  the  amount  of  hunicUi  tuberculosis  of  bovine  origin, 
we  can  onl\-  allude  briefly  to  the  estimates  which  have  been 
made  b>'  various  authorities,  calling  attention  especially 
to  the  researches  of  the  British  and  Ciernian  Commissions 
and  of  Park  and  Krumwiede  of  the  Research  Laboratory 
of  New  York  City. 

"It  is  now  estimated,"  according  to  Rosenau,  "that 
perhaps  7  per  cent  of  the  tuberculosis  in  man  is  of  bovine 
origin."  ^  The  great  bulk  of  the  human  tuberculosis 
bacteriologically  identified  as  bovine  is  in  the  form  of 
generalized,  abdominal  and  glandular  tuberculosis  of  chil- 
dren. In  a  summary  of  the  researches  Rosenau  -  states 
that  "about  one-quarter  to  one-half  of  all  cases  of  tuber- 
culosis in  children  under  5  years  of  age  is  associated  with 
the  bovine  type,"  probably  derived  in  all  cases  from  cow's 
milk.  Park  has  estimated,  on  the  basis  of  the  various 
available  researches,  that  in  New  York  City: 

About  7  per  cent  of  the  infants  and  young  children  under  5  years 
of  age  dying  from  tuberculosis  do  so  because  of  infection  derived  from 
infected  milk  or  milk  products.  Fatal  tuberculosis  due  to  bovine 
bacilli  is  rare  in  those  over  5  years  of  age,  but,  on  the  other  hand,  in- 
fection of  the  lymph  nodes  is  frequent;  30  per  cent  or  more  of  tuber- 
cular lymph  nodes  occurring  in  children  between  5  and  16  are  contracted 
through  bovine  bacilli.  Judging  from  the  296  cases  examined,  pulmo- 
nary tuberculosis  is  practically  always  due  to  the  human  type,  that  is, 
contracted  from  other  cases,  and  not  from  milk.^ 

Applying  Dr.  Park's  figure  to  the  percentage  of  deaths 
from  tuberculosis  under  five  years  of  age  in  the  Registration 

'  "  Preventive  Medicine  and  Hygiene,"  1913,  p.  124. 

-  Loc.  cit. 

^  "  The  Role  of  Bovine  Tuberculosis  in  the  Production  of  Human 
Tuberculosis,"  Trans.  XV  Inlernat.  Congress  on  Ilyg.  and  Deniogr., 
1912,  vol.  IV,  pp.  267-72  (an  admirable  summing-up  of  the  whole 
subject).  It  is  scarcely  necessary  to  note  that  (as  implied  by  the  word 
which  we  have  italicized  above)  the  many  cases  of  tubercular  infection 
which  do  not  result  fatally  should  be  considered  in  addition  to  the  above 
estimate. 


MILK  AND   OTIIKR    FOOD    SUI'I'IJKS  351 

Area  (approximately  7  per  cent  of  the  total  tuberculosis), 
would  give  about  one-half  of  I  per  cent  of  all  tuberculosis 
deaths  as  definitely  due  to  the  l)ovine  type.  Ravcnel  ' 
believes  that  there  is  a  possibility  of  the  bovine  bacillus 
changing  its  type  after  becoming  rooted  in  the  human  sub- 
ject, which,  if  true,  would  make  the  numbers  of  cases  of 
bovine  origin  in  excess  of  the  apparent  figures.  This,  how- 
ever, has  not,  it  appears,  been  demonstrated. 

There  is  reason  for  believing  that  all  persons  are  infected 
with  the  bovine  bacillus  in  infancy  through  the  ingestion 
of  cow's  milk,  but  that  the  development  of  immunity  in  the 
great  majority  of  cases  prevents  the  development  of  the 
disease.  From  the  figures  just  quoted  it  is  to  be  seen  that 
the  actual  proportion  of  human  tuberculosis  from  bovine 
sources  which  has  thus  far  been  demonstrated  is  not  great 
as  compared  with  the  total  from  all  sources.  The  absolute 
numbers  of  cases,  however,  may  be  considerable.  Below 
will  be  considered  what  measures  may  be  adopted  to 
avoid  them. 

The  Tuberculin  Test.  —  The  tuberculin  test  -  is 
accepted  as  the  standard  test  for  tuberculosis  in  animals 
when  the  disease  cannot  be  definitely  detected  by  physical 
examination.  The  International  Commission  on  the  Con- 
trol of  Bovine  Tuberculosis  resolved  in  1910  that  "tuber- 
culin, properly  used,  is  an  accurate  and  reliable  diagnostic 
agent  for  the  detection  of  active  tuberculosis;"  a  decision 
affirmed  legally  by  the  opinion  of  the  court  in  the  Montclair 
and  other  cases.^ 

"■  See  discussion  of  Dr.  Park's  paper  just  cited. 

2  The  test  consists  in  the  hypodermic  injection  into  the  suspected 
animal  of  a  measured  amount  of  an  emulsion  of  killed  bovine  tubercle 
bacilli  (tuberculin).  The  temperature  of  the  animal  is  taken  at  certain 
intervals  for  some  hours  afterwards;  animals  having  tuberculous  in- 
fection "  react  "  by  a  marked  rise  in  temperature.  The  tuberculin 
reaction  has  been  accepted  legally,  as  well  as  in  veterinary'  medicine,  as 
a  thoroughly  reliable  test  when  in  proper  hands.  See  decision  in  Mont- 
clair case.  Appendix  C. 

'  See  Appendix  C. 


352  A   MANUAL   FOR  HEALTH   OFFICERS 

Officials  of  the  U.  S.  Department  of  Agriculture  ^  have 
demonstrated  that  tuberculous  cattle  discharge  tubercle 
bacilli  in  their  feces,  the  chief  source  of  these  being  the 
sputum  of  the  animals,  which,  after  being  coughed  up,  is 
swallowed  and  passes  through  the  alimentary  canal  with- 
out the  bacilli  losing  their  virulence.  They  showed,  fur- 
thermore, that  "the  cattle  that  pass  tubercle  bacilli  per 
rectum  are  not  always  visibly  diseased.  Many  apparently 
healthy  but  tuberculous  cattle  which  are  not  known  to  be 
tuberculous  until  they  are  tested  with  tuberculin,  inter- 
mittently pass  tubercle  bacilli  from  their  bodies  per  rectum 
with  their  feces."  In  some  cases  the  germs  may  also  get 
into  the  milk  directly  from  tuberculosis  of  the  udder. 

In  Appendix  C  will  be  found  a  review  of  the  Montclair 
and  other  cases  by  which  the  powers  of  health  authorities 
to  require  that  milk,  as  judged  by  this  test,  be  tuberculosis- 
free,  are  supported. 

Evidence  from  four  typical  American  cities,  summed  up 
by  Rosenau,-  shows  that  out  of  a  total  of  551  samples  of 
market  milk  examined  tube^clc  bacilli  were  found  in  46,  or 
8.3  per  cent,  a  figure  which  may  be  taken  as  an  approximate 
percentage  for  the  country.  Even  this  figure  is  doubtless 
an  underestimate,  for  the  laboratory  methods  do  not  always 
detect  bacilli  which  are  present  only  in  small  numbers.  In 
Rochester,  N.  Y.,  among  185  retailers  12.65  per  cent  of  the 
milk  samples  examined  reacted  positive  to  animal  tests  for 
tuberculosis.^  Unfortunately  such  tests  give  no  indication 
as  to  the  numbers  of  tubercle  bacilli  in  the  samples. 

A  serious  economic  question  arises  when  the  tuberculin 
test  is  applied  to  dairy  cattle  and  it  is  proposed  to  eliminate 
the  milk  of  reacting  animals  from  the  public  supply.  Some 
idea  of  the  relative  numbers  of  reactors  is  given  by  the 

^  Shroeder  and  Cotton,  Bulletin  99  (1907)  and  Circular  118  (1907), 
Bureau  of  Animal  Industry,  Dept.  of  Agriculture. 

^  "  Preventive  Medicine  and  Hygiene,"  1913,  p.  513. 

'  Goler,  2nd  Ann.  Travis.  Am.  Assn.  for  Study  and  Prev.  of  Infant 
Mortality,  191 1. 


MILK   AND   OTHER    lOOl)    sm'I'L/i;S  353 

experience  of   Moiitclair,    N.   J.,   when   its   tuberculin-test 
ordinance  went  into  effect  in  1907: 

Of  the  New  Jersey  cows  that  had  not  been  previously  tested,  25  per 
cent  reacted.  Many  of  the  figures  that  arc  availaljle  on  the  suV^ject 
.  .  .  relate  to  suspected  or  picked  herds,  whereas  the  percentage 
of  reactions  above  mentioned  represents  conditions  of  herds  taken 
practically  at  random  over  a  considerable  area,  with  the  exceptions  that 
they  had  more  than  the  average  veterinary  inspection,  and  that  they 
have  been  stabled  under  good  conditions.' 

In  individual  herds  a  quarter  to  a  half  or  even  three- 
quarters  of  the  animals  may  react.  The  enforcement  of 
such  a  regulation  would  result  in  a  serious  diminution  of 
the  herds,  a  large  financial  loss  to  the  dairymen  and  a  great 
lessening  in  milk  supply  with  a  resultant  increase  in  cost  of 
the  product.  This  problem  has  been  met  in  some  instances, 
e.g.,  New  York  State,  by  legal  reimbursement  of  the  owner 
for  a  large  part  of  the  loss  sustained  by  the  slaughter  of 
tuberculous  cattle.  However  the  loss  is  met,  it  is  a  real 
loss;  if  private,  it  means  injustice  to  the  cattle-owner;  and 
if  public,  it  must  result  in  a  higher  real  cost  of  milk  supplies, 
whether  paid  through  taxes  for  reimbursement  of  dairymen 
for  rejected  cattle  or  through  an  increased  price  for  market 
milk. 

The  milk  from  cattle  having  tuberculosis  to  an  extent 
detectable  by  ordinary  physical  veterinary  examination 
should  be  excluded.  But  when  there  is  question  of  the  use 
of  milk  from  cows,  apparently  healthy,  which  simply  react 
to  the  tuberculin  test,  then  there  is,  as  will  be  shown  below, 
a  practical  alternative  to  elimination  of  the  milk  from  these 
animals,  viz.,  pasteurization.  If,  however,  milk  is  to  be 
consumed  raw  (e.g.,  certified  milk),  then  it  can  only  be  pro- 
tected from  tuberculosis  by  enforcing  the  tuberculin  test. 

It  scarcely  need  be  said  that  the  elimination  of  tubercu- 
losis in  dairy  herds  by  scientific  methods  constitutes  a  large 

1  Wells,  "  The  Successful  Efforts  of  a  Small  City  to  Secure  a  Milk 
Supply  from  Tuberculin-Tested  Cows,"  Am.  Jour.  Pub.  Health,  1912, 
vol.  II,  no.  9,  p.  702. 


354  A  MANUAL   FOR   HEALTH   OFFICERS 

economic  liroblcin  for  veterinarians  and  dairymen,  quite 
apart  from  considerations  of  human  hygiene. 

Other  diseases  transmissible  to  man  through  milk,  but 
occurring  comparatively  infrequently,  are: 

Milk  sickness,  an  acute,  non-febrile  disease  due  to  the 
ingestion  of  milk,  milk  products,  or  the  flesh  of  animals 
suffering  from  a  disease  known  as  trembles.  The  disease 
is  characterized  by  great  depression,  persistent  vomiting, 
obstinate  constipation  and  high  mortality. 

Foot-and-mouth  disease,  an  infection  primarily  of  cattle 
and  secondarily  of  man.  In  man  the  disease  is  mild  and 
the  symptoms  resemble  those  observed  in  animals. 

Malta  fever ,  transmitted  from  goats  to  man  through  milk. 

PASTEURIZATION 

Definition.  —  Pasteurization  is  the  term  applied  to  any 
process  of  heating  milk  (or  other  substance)  to  a  sufficient 
temperature  and  holding  it  at  that  temperature  sufficiently 
long  to  destroy  nearly  all  the  germs  present.  If  the  process 
is  properly  performed  any  disease-producing  germs  present 
are  killed,  the  surviving  organisms  being  harmless  varieties. 
It  has  been  shown  that  all  of  the  lactic  acid  germs,  which 
cause  the  souring  of  milk,  need  not  be  destroyed;  this  has 
an  important  practical  bearing,  for  if  the  care  of  milk  after 
pasteurization  chances  to  be  neglected  it  is  highly  desirable 
that  it  should  sour  rather  than  undergo  a  very  much  more 
dangerous  alkaline  decomposition  with  production  of  pto- 
maines and  the  like.  (See  previous  remarks  under  head  of 
bacterial  decomposition.) 

Pasteurization  should  not  be  confused  with  sterilization. 
Sterilization  means  the  destruction  of  all  germs,  and  requires 
heating  to  the  boiling  point.  (Perfect  sterilization  requires 
such  treatment  on  three  successive  days.)  There  are  great 
differences  between  the  chemical  changes  which  take  place 
in  milk  heated  to  various  temperatures  for  various  lengths 


MILK   AND    O'l'IfKR    f-'OOF)    SUIM'LIES  355 

of  time,  and  these  have  been  the  cause  of  dispute  and  mis- 
understanding through  failure  to  make  use  of  exact  defini- 
tions. Pasteurization  is  a  gen(;ral  term  covering  various 
processes  having  a  similar  elfect,  and  being  thus  general, 
should  be  defined  for  purposes  of  practice  and  discussion. 
The  Commission  on  Milk  Standards  of  the  New  York 
Committee  ^  (2nd  Report)  reports  on  the  subject  of  pas- 
teurizing temperatures  as  follows: 

The  commission  passed  a  resolution  regarding  the  temperature  of 
pasteurization  as  follows: 

That  pasteurization  of  milk  should  be  between  the  limits  of  140°  F.  and 
155°  ^-  -^l  140°  F.  the  minimum  exposure  should  be  20  minutes.  For 
every  degree  above  140°  F.  the  time  may  be  reduced  by  i  minute.  In  no  case 
should  the  exposure  be  for  less  than  5  minutes. 

In  order  to  allow  a  margin  of  safety  under  commercial  conditions 
the  commission  recommends  that  the  minimum  temperature  during 
the  period  of  holding  should  be  made  145°  F.  and  the  holding  time 
30  minutes.  Pasteurization  in  bulk  when  properly  carried  out  has 
proven  satisfactory,  but  pasteurization  in  the  final  container  is  pref- 
erable. 

It  is  the  sense  of  the  commission  that  pasteurization  in  the  final 
container  should  be  encouraged. 

The  definition  italicized  above  should  be  adopted  by 
health  authorities  for  all  practical  purposes  and  the 
added  recommendation  should  be  observed  by  milk  deal- 
ers. Proper  pasteurization  does  not  affect  the  taste  or 
chemical  characteristics  of  the  milk,  nor  does  it  prevent 
the  rising  of  cream,  though  higher  temperatures  or  greater 
lengths  of  time  may  do  so. 

Contrary  to  opinions  which  have  been  expressed  by  some 
in  the  past,  proper  pasteurization  does  not  exert  any  deleterious 
influence  upon  the  chemical  or  nutritive  value  of  milk.~  Even 
boiled  milk  is  apparently  exonerated  by  recent  investiga- 

^  See  p.  362. 

2  Kastle,  Bull.  56,  Hj-g.  Lab.  U.  S.  Pub.  Health  Service,  and  Rupp, 
Bull.  166,  U.  S.  Bureau  of  Animal  Industry  (quoted  by  Magruder, 
ref.  at  close  of  this  chapter). 


356  A   MANUAL   FOR  HE.\LTH  OFFICERS 

lions  from  the  accusation  of  producing  adverse  effects  in 
infants  and  youn;j;  children.^  Rosenau  states  that  "the 
evidence  seems  clear  to  me  that  these  two  diseases  [scurvy 
and  rickets]  bear  no  relation  whatever  to  the  heating  of  the 
milk."  -  So  much  for  the  clinical  and  prophylactic  aspects 
of  tlie  case. 

The  Argument  for  Pasteurization.  —  The  administrative 
argument  for  pasteurization  is  based  upon  the  fact,  proved 
over  and  over  again,  that  proper  pastenrizatiofi  of  milk  sup- 
plies is  the  only  certain  safeguard  against  milk-borne  infectious 
disease.  Even  with  the  most  careful  and  frequent  inspec- 
tion and  the  promptest  and  fullest  reporting  of  cases  by 
physicians  it  is  impossible  to  guard  against  the  infection  of 
milk  supplies  by  carriers,  missed  cases  and  incipient  cases 
of  typhoid  fever,  diphtheria,  scarlet  fever,  septic  sore  throat 
and  other  communicable  diseases.  Such  cases  are  certain 
to  occur  from  time  to  time  among  persons  engaged  in  han- 
dling milk  at  the  different  stages,  in  the  families  of  dairy- 
men, etc.  Against  this  certainty,  which  is  only  a  matter 
of  time,  communities  using  raw  milk  are  taking  a  chance 
which  on  any  day  may  prove  fatal.  These  considerations 
are  concurred  in  by  all  authorities  on  the  basis  of  hun- 
dreds of  recorded  outbreaks  which  have  already  occurred. 
In  a  number  of  such  instances  it  has  been  shown  that  even 
great  cleanliness,  as  ordinarily  understood  in  the  production 
and  handling  of  milk,  while  diminishing  the  chances  of 
infection,  has  by  no  means  prevented  infection;  even  certi- 
fied milk  supplies  have  not  escaped  infection. 

Again,  through  pasteurization,  infection  from  animal 
sources,  and  particularly  bovine  tuberculosis,  is  absolutely 
eliminated.  Not  only  is  safety  thus  obtained,  but  a  great 
economic  saving  is  effected,  since  the  milk  of  those  (other- 
wise healthy)  cows  which  react  to  the  tuberculin  test  may 
be  safely  used  when  it  has  been  pasteurized.     The  elimina- 

*•  Magruder,  op.  cit. 

*  "Preventive  Medicine  and  Hygiene,"  1913,  p.  519. 


MILK   AND   OTIIKk    KOOlJ    SUI'I'fJKS  357 

tion  of  tulicrculosis  among  cattle  iiivf)lvcs  (lirficiill  i)io!>lcms 
and  will  not  be  accomplished  for  many  years  to  ( fMiie. 
But,  fortunately,  instead  of  the  destruction  of  non-tuljcrculin- 
tested  cattle,  pasteurization  of  milk  may  {and  should)  he  re- 
quired. This,  assuming  that  the  i)astcurization  is  \)X<)\)i-x\y 
performed  under  adeciuate  official  control  (see  below j,  is 
the  practical  solution  of  the  problem. 

Finally,  through  pasteurization,  germs  —  other  than 
those  of  the  above-mentioned  diseases  —  which  al;ound 
even  in  milk  produced  under  what  are  regarded  as  moder- 
ately good  conditions,  are  destroyed  and  thus  is  the  milk 
rendered  in  general  ajar  safer  food  for  infants,  young  children 
and  invalids,  with  the  result  of  a  corresponding  reduction 
in  the  occurrence  of  gastro-intestinal  disorders  and  an  in- 
crease in  vital  resistance  to  other  diseases.  A  large  number 
of  authorities  might  be  cited  to  illustrate  this  point.  Re- 
searches conducted  in  connection  with  the  Rockefeller 
Institute  of  Medical  Research  have  shown,  in  the  words  of 
Dr.  W.  H.  Park  of  the  New  York  City  Department  of 
Health,  "that  mother's  milk  is  the  best  milk  for  a  baby  and 
that  pasteurized  milk  is  the  next  best."  This  was  proved 
by  the  fact  that  babies  changed  from  pasteurized  milk  to 
good  raw  milk  became  ill.^ 

It  has  been  remarked  that  pasteurization  is  not  an  "ideal " 
measure.  The  question,  however,  is  one  of  expediency, 
and  since  it  is  a  practical  impossibility  to  secure  infection- 
free  and  low-bacteria  raw  milk  supplies,  this  method  must 
be  adopted  to  destroy  bacteria  and  infection.  This  "puri- 
fication" of  milk  supplies  is  analogous  to  the  purification 
of  water  supplies,  with  the  difference  that  originally  safe 

1  Cf.  Straus,  "  Saving  Children  from  Milk-Borne  Diseases,"  Am. 
Jour.  Pub.  Health,  191 1,  vol.  I,  no.  2,  p.  109,  and  "  Disease  in  Milk  — 
The  Remedy:  Pasteurization,"  by  Lena  G.  Straus,  New  York,  1913 
(both  describing  methods  used  and  results  obtained  in  the  dispensing 
of  pasteurized  milk  from  the  celebrated  Straus  stations  in  New  York 
City);  and  papers  in  Trans.  XV  Intern.  Congress  Hyg.  and  Demogr., 
1912,  vol.  IV. 


358  A   MANUAL   FOR   HEALTH  OFFICERS 

water  supplies  may  frequently  be  obtained,  whereas  this  is 
not  true  of  milk  supplies. 

The  case  for  pasteurization  may  be  closed  by  remarking 
that  the  Commission  on  Milk  Standards  to  which  we  have 
already  alluded  has  recommended  unanimously  that  all 
milk  be  pasteurized  with  the  possible  exception  of  that  of 
the  very  first  grade  (Grade  "A") — which  constitutes  in 
any  case  but  a  very  small  proportion  of  the  whole  milk 
supply  —  and  the  majority  of  the  commissioners  voted  in 
favor  of  the  pasteurization  of  all  milk  including  even  this 
class. 

Cautions  in  Connection  with  Pasteurization.  — 
The  so-called  objections  against  pasteurization  may  be 
mentioned  here  simply  as  cautions.  It  is  truly  said  that 
pasteurization  may  be  used  as  a  cloak  for  bad  milk,  in 
efforts  to  redeem  bacteria-laden  milk  which  would  other- 
wise be  unsalable.  The  heating  process,  while  destroying 
bacteria,  does  not  remove  the  products  of  bacterial  decom- 
position. Filth  in  milk,  though  pasteurized,  is  none  the 
less  filth.  Hence  pasteurization  can  in  no  way  take  the  place 
of  precautions  as  to  cleanliness  and  handling.  Inspection 
work  should  not  be  diminished  but  rather  increased  when 
pasteurization  is  employed.  This  is  not  an  objection  but 
simply  a  precaution  in  connection  with  the  process.  As 
Ay  res  has  remarked,  the  object  is.  not  to  try  to  make  a 
dirty  milk  a  clean  milk  (an  impossibility)  but  to  make  a 
clean  milk  a  safe  milk. 

Another  caution,  relating  to  the  adequacy  of  the  process, 
will  be  taken  up  in  the  next  paragraph. 

Control.  —  Pasteurization  is  a  scientific  process  which 
should  be  carried  out  under  expert  management  and  under 
official  stcpervision.  Commercial  methods  should  be  thor- 
oughly inspected  and  approved  before  the  designation 
"pasteurized"  is  permitted  to  be  used,  and  then  should  be 
as  frequently  as  possible  reinspected.  Automatic  tem- 
perature regulators  and  recording  thermometers  should  be 


MFLK    AND   ()TIIF;|^    F'Y)f)I)    SUf'I'LFKS  359 

required  in  plants,  and  the  processes  should  be  checked  hy 
frequent  bactcriolf)gical  tests.  Mucli  harm  has  been  done 
by  the  exploitation  as  pasteurised  of  improperly  treated 
milk. 

Methods.  —  In  some  countries  it  is  the  custom  of  the 
people  to  heat  or  boil  the  milk  used  for  domestic  purposes, 
with  beneficial  results  in  the  avoidance  of  infection,  etc. 
And  at  the  present  time,  wliercvcr  public  milk  supplies  are 
not  commercially  pasteurized  before  delivery,  the  private 
family  may  protect  itself  by  home  pasteurization,  which 
we  have  already  described.^  This,  however,  is  not  satis- 
factory any  more  than  reliance  upon  the  public  to  boil  con- 
taminated public  water  supplies;  it  is  not  altogether  simple, 
cannot  be  taught  on  a  large  scale  and  is  beyond  the  intelli- 
gence or  willingness  of  many  people.  The  only  adequate 
measure  is  the  requirement  of  pasteurization  of  all  com- 
mercial milk  supplies  under  close  official  supervision. 

The  two  methods  in  common  commercial  use  are  the  flash 
method  and  the  holding  method.  In  the  former  the  milk  is 
run  over  hot  pipes  and  heated  to  a  high  temperature  for 
a  very  short  time  —  say  one-half  to  one  minute.  In  the 
latter  the  milk  is  raised  to  a  lower  temperature  but  held  in 
tanks  for  a  much  longer  time;  140°  F.  for  20  minutes  or 
more  would  constitute  a  proper  pasteurization  according 
to  this  method.  Experiment  has  shown  that  the  flash 
method  is  not  satisfactory,  does  not  always  produce  the 
required  bacterial  reduction,  and  is  subject  to  grave  varia- 
tions. Hence  it  is  excluded  by  the  definition  of  the  Com- 
mission on  Milk  Standards  which  we  have  quoted,  and 
should  not  be  allowed.  Reliable  dealers  use  holding  ma- 
chines with  automatic  devices  which  absolutely  insure  the 
proper  temperature  and  length  of  time,  using  a  temperature 
of  145°  F.  for  30  minutes.  "By  the  holding  process 
properly  conducted  it  is  usual  to  destroy  99.93  to  99.99  per 
cent    of    the    bacteria"    (Magruder).     Regulation    should 

'  P.  311. 


360  A  MANUAL   FOR   HEALTH   OFFICERS 

regard  the  final  count,  th()Ui;li  the  initial  count  before 
pasteurization  should  also  be  subject  to  control  (see  Rules, 
Appendix  B).  Since  all  the  bacteria  arc  not  killed  it  is 
essential  that  pasteurized  milk  be  promptly  cooled  as  held 
at  as  low  a  temperature  as  raw  milk  would  be  (50°  F.  or 
below  —  Commission  on  Milk  Standards).  Furthermore, 
the  greatest  cleanliness  should  be  insisted  upon  in  pasteuri- 
zing plants  and  the  apparatus  should  be  cleaned  and 
sterilized  with  live  steam  daily  in  order  that  there  may  be  no 
contamination  of  the  milk  before  or  after  the  process;  and 
the  milk  should  be  immediately  run  into  sterilized  bottles. 
The  process  most  recommended  by  sanitarians,  though 
it  has  some  practical  difficulties,  is  pasteurization  in  the  final 
container.  This  has  the  great  advantage  of  allowing  no 
contamination  subsequent  to  the  process  and  before  deliv- 
ery to  the  consumer.  The  bottles  must  have  water-tight 
seal  caps  and  are  immersed  in  hot  water,  held  for  pre- 
scribed temperature  and  time  (say  145  degrees  for  20  to  30 
minutes),  and  cooled  by  lowering  of  the  temperature  of  the 
surrounding  water.  The  economic  drawback  is  the  cost 
of  the  caps.  Care  must  be  taken  that  the  whole  mass  of 
milk  in  the  container  is  heated  and  held  sufhciently.  As  a 
practical  modification  it  has  been  suggested  that  milk  be 
pasteurized  according  to  the  holder  system  and  then  be  run 
while  hot  into  bottles  which  have  just  been  steamed.  In 
this  case  ordinary  caps  could  be  used  and  the  bottles  could 
be  cooled  by  a  cold  air  blast.  Further  data  are  to  be  looked 
for  in  the  study  of  this  process,  looking  toward  its  adaptation 
to  commercial  use.^ 

^  Ayres,  "  The  Present  Status  of  Pasteurization,"  Am.  Jour.  Pub. 
Health,  1914,  vol.  IV,  no.  I,  p.  15.  Cf.  Bulls.  166,  126,  161,  and  espe- 
cially 184,  Bureau  of  Animal  Industry.  Other  details  of  pasteurization 
methods  are  given  by  North,  "  The  Holding  Method  of  Milk  Pas- 
teurization," Eng'g  News,  1910,  vol.  63,  no.  19,  p.  570;  Kilbourne, 
"  Pasteurization  of  Milk,  with  Suggestions  as  to  Methods  and  Appara- 
tus to  be  Employed,"  Am.  Jour.  Puh.  Health,  1912,  vol.  II,  no.  8,  p. 
626;  Kilbourne,  "  The  Control  of  Temperatures  in  the  Pasteurization 
of  Milk,"  Am.  Jour.  Puh.  Health,  1913,  vol.  HI,  no.  3,  p.  268. 


MILK   AND   OTHER    RJOD    SUPI'LIKS  361 

Other  methods  of  purification  of  milk  have  from  time  to 
time  been  proposed.  Thus  gotxl  results  from  partial  steril- 
ization by  electricity  have  been  reported  (Liverpool,  191 3). 
But  none  of  these  have  thus  far,  so  far  as  the  writer  knows, 
proved  as  economical  and  practically  effective  as  pasteuri- 
zation, and  none  are  in  general  use. 

THE   REGULATION    OF   MILK    SUPPLIES 

The  objects  of  regulation  may,  for  convenience,  be  reca- 
pitulated as  follows  (cf .  page  345) : 

1.  The  competent  veterinary  examination  of  dairy  cattle 
and  elimination  of  those  shown  on  physical  examination 
to  be  diseased. 

2.  Cleanliness  of  stables,  animals,  utensils,  etc.,  and 
especially  of  methods  of  production  and  handling,  all  along 
the  line  from  the  cow  to  the  consumer. 

3.  Maintenance  of  the  milk  continuously  at  a  sufificiently 
low  temperature.  Prohibition  of  the  sale  of  stale  milk  and 
milk  showing  an  excessive  bacterial  count. 

4.  Sufhcient  food  values  and  freedom  from  adulteration 
(as  through  watering,  skimming  and  the  like),  sophistica- 
tion and  the  use  of  preservatives. 

5.  Prevention  of  infection,  human  or  animal  in  source, 
through  requirements  as  to  health  of  employees,  reporting 
of  communicable  disease  in  families  of  any  persons  con- 
cerned in  the  handling  of  milk  supplies,  regulations  as  to 
delivery  of  milk  to  infected  families,  purity  of  dairy  water 
supplies,  and  finally,  most  important,  sterilization  of  milk 
utensils  and  apparatus  and  pasteurization  of  all  milk  with 
the  possible  exception  of  the  very  highest  grade.  (For 
application  of  the  tuberculin  text,  see  preceding  discussion 
of  the  subject.) 

Regulations  covering  in  detail  the  above  points  should  be 
adopted  by  local  authorities,  such  regulations  being  based 
upon  the  recommendations  of  the  Commission  on  Milk 
Standards   described   below.     Funds   should   be   provided 


362  A   MANUAL   FOR  HEALTH  OFFICERS 

for  sufficient  inspection  and  laboratory  work  to  enforce 
the  standards  adopted ;  in  the  larger  towns  a  special  milk 
inspector,  who  may  perhaps  also  act  as  analyst,  if  his  in- 
spection duties  permit,  should  be  appointed. 

MILK  STANDARDS 

The  standards  adopted  by  local  health  authorities  in 
their  regulation  of  milk  supplies  should  conform  as  closely 
as  practicable  to  those  which  have  been  formulated  by  the 
Commission  on  Milk  Standards  appointed  by  the  New  York 
Milk  Committee.  This  commission  consists  of  seventeen 
experts  brought  together  for  the  purpose  of  clearing  up  the 
confusion  due  to  the  multifarious  requirements  which  have 
been  promulgated  by  the  various  health  authorities  of  the 
country,  a  purpose  which  has  been  accomplished  by  the 
formulation  of  definite  regulations  for  adoption  by  com- 
munities of  all  sizes.  The  Commission  is  therefore  truly  a 
national,  though  unofficial,  body  and  its  decisions  are  to  be 
respected  accordingly.  The  requirements  formulated  by 
it  have  been  approved  by  the  International  Milk  Dealer's 
Association  (of  the  United  States  and  Canada),  the  Ameri- 
can Public  Health  Association  and  other  bodies.  These 
requirements  can  only  be  made  effective,  however,  through 
incorporation  into  the  local  ordinances  of  each  community, 
an  aim  for  which  the  New  York  Milk  Committee  is  con- 
ducting a  campaign. 

The  most  salient  of  the  Commission's  recommendations 
refer  to  the  importance  of  pasteurization  and  to  the  estab- 
lishment of  definite  market  grades  of  milk,  to  be  produced 
under  specified  conditions  and  to  be  labeled  according  to 
grade.  Other  recommendations  deal  with  standards  for 
bacteria  and  for  total  solids  and  fats,  with  the  method  of 
pasteurization,  with  the  details  of  production  and  handling, 
and  with  the  regulation  of  cream  supplies,  covering  suc- 
cinctly all  the  chief  points  of  the  milk  problem. 


MILK    AND    O'l'llllk    l(K)h    SUI'I'IJKS  363 

Since  Lhc  rc[)orLs  of  Llic  Commission  arc  readily  available 
and  may  be  altered  in  detail  from  year  to  year,  we  shall 
here  give  only  the  chief  recommendations.  The  entire 
report  should,  however,  be  considered  in  detail  by  all  local 
health  officers.^ 

Classification  of  Milks.  —  The  most  important  feature 
of  the  report  of  the  Commission  is  the  recommendation 
that  all  market  milks  be  classified  on  a  sanitary  basis,  to  be 
graded  by  the  health  authorities  by  ordinanc(',  inspection 
and  analysis  and  to  be  so  marked  in  the  trade." 

There  is  no  escape  from  the  conclusion  that  milk  must  be  graded  and 
sold  on  grade,  just  as  wheat,  corn,  cotton,  beef  and  other  products 
are  graded.  The  milk  merchant  must  judge  of  the  food  value  and 
also  of  the  sanitary  character  of  the  commodity  in  which  he  deals. 
The  high-grade  product  must  get  a  better  price  than  at  present.  The 
low-grade  product  must  bring  less.  In  separating  milk  into  grades 
and  classes  the  commission  has  endeavored  to  make  its  classification 
as  simple  as  possible  and  at  the  same  time  to  distinguish  between  milks 
which  are  essentially  different  in  sanitary  character. 

In  general  two  great  classes  of  milk  are  recognized,  namely,  raw 
milk  and  pasteurized  milk.  Under  these  general  classes  there  are 
different  grades.  .  .  . 

Milk  shall  be  divided  into  three  grades,  which  shall  be  the  same  for 
both  large  and  small  cities  and  towns,  and  which  shall  be  designated 
by  the  first  three  letters  of  the  alphabet.  The  requirements  shall  be 
as  follows: 


1  Copies  of  the  Report  maj^  be  obtained  from  the  New  York  Milk 
Committee,  105  East  22nd  Street,  New  York  City,  or  (at  five  cents  per 
copy)  from  the  Superintendent  of  Documents,  Government  Printing 
Office,  Washington,  D.  C. 

^  A  grading  and  labeling  of  milk  on  the  same  general  lines  as  those 
laid  down  by  the  Commission  on  Milk  Standards  has  been  put  in  effect 
by  the  Health  Department  of  New  York  Cit}-,  the  grades  being  based 
explicitly  upon  the  use  to  which  the  milk  is  to  be  put,  thus:  A.  Milk 
suitable  for  infant  feeding;  B.  Milk  suitable  for  adults  to  drink;  and  C. 
Milk  for  cooking  and  manufacturing  purposes.  Emphasis  is  placed  on 
'  pasteurization,  and  under  present  regulations  nearly  the  entire  city  milk 
supply  must  be  pasteurized.  It  is  expected  that  in  the  near  future  a 
number  of  progressive  towns  and  cities  will  adopt  the  grading  system 
as  the  only  scientific  and  practical  means  of  controlling  milk  supplies. 


364  A  MANUAL   FOR   HEALTH  OFFICERS 


Raw  Milk.  —  Milk  of  this  class  shall  come  from  cows  free  from  disease 
as  determined  by  tuberculin  tests  and  physical  examinations  by  a 
qualified  veterinarian,  and  shall  be  produced  and  handled  by  employees 
free  from  disease  as  determined  by  medical  inspection  of  a  qualified 
physician,  under  sanitary  conditions  such  that  the  bacteria  count  shall 
not  exceed  100,000  per  cubic  centimeter  at  the  time  of  delivery  to  the 
consumer.  It  is  recommended  that  dairies  from  which  this  supply  is 
obtained  shall  score  at  least  80  on  the  United  States  Bureau  of  Animal 
Industry  score  card. 

Pasteurized  Milk.  —  Milk  of  this  class  shall  come  from  cows  free  from 
disease  as  determined  by  physical  examinations  by  a  qualified  veteri- 
narian and  shall  be  produced  and  handled  under  sanitary  conditions  such 
that  the  bacteria  count  at  no  time  exceeds  200,000  per  cubic  centimeter. 
All  milk  of  this  class  shall  be  pasteurized  under  official  supervision,  and 
the  bacteria  count  shall  not  exceed  10,000  per  cubic  centimeter  at  the 
time  of  delivery  to  the  consumer.  It  is  recommended  that  dairies  from 
which  this  supply  is  obtained  should  score  65  on  the  United  States 
Bureau  of  Animal  Industry'  score  card. 

The  above  represents  only  the  minimum  standards  under  which 
milk  may  be  classified  in  grade  A.  The  commission  recognizes,  how- 
ever, that  there  are  grades  of  milk  which  are  produced  under  unusually 
good  conditions,  in  especially  sanitary  dairies,  many  of  which  are 
operated  under  the  supervision  of  medical  associations.  Such  milks 
clearly  stand  at  the  head  of  this  grade. 


Milk  of  this  class  shall  come  from  cows  free  from  disease  as  deter- 
mined by  physical  examinations,  of  which  one  each  year  shall  be  by  a 
qualified  veterinarian,  and  shall  be  produced  and  handled  under  sani- 
tary conditions  such  that  the  bacteria  count  at  no  time  exceeds  1,000,000 
per  cubic  centimeter.  All  milk  of  this  class  shall  be  pasteurized  under 
official  supervision,  and  the  bacteria  count  shall  not  exceed  50,000  per 
cul)ic  centimeter  when  delivered  to  the  consumer. 

It  is  recommended  that  dairies  producing  grade  B  milk  should  be 
scored  and  that  the  health  departments  or  the  controlling  departments, 
whatever  they  may  be,  strive  to  bring  these  scores  up  as  rapidly  as 
possible. 

GRADE   C 

Milk  of  this  class  shall  come  from  cows  free  from  disease  as  deter- 
mined by  physical  examinations  and  shall  include  all  milk  that  is  pro- 
duced under  conditions  such  that  the  bacteria  count  is  in  excess  of 
1,000,000  per  cubic  centimeter. 


MILK    ANI>   (rniKR    FOOD    SUI'PLIKS  365 

All  milk  of  this  class  shall  be  pasteurized,  or  heated  to  a  hiyher  tem- 
perature, and  shall  contain  less  than  50,000  bacteria  per  cubic  centi- 
meter when  delivered  to  the  customer.  It  is  recommended  that  this 
milk  be  used  for  cooking  or  manufacturing  purposes  only. 

Whenever  any  large  city  or  community  finds  it  necessary,  on  account 
of  the  length  of  haul  or  other  peculiar  conditions,  to  allow  the  sale  of 
grade  C  milk,  its  sale  shall  I^e  surrounded  jjy  safeguards  such  as  to  insure 
the  restriction  of  its  use  to  cooking  and  manufacturing  purjjoses. 

The  report  adds:  ^ 

Cream  should  be  classified  in  the  same  grades  as  milk,  in  accordance 
with  the  requirements  for  the  grades  of  milk,  excepting  the  bacterial 
standards,  which  in  20  per  cent  cream  shall  not  exceed  five  times  the 
bacterial  standard  allowed  in  the  grade  of  milk. 

Cream  containing  other  percentages  of  fat  shall  be  allowed  a  modi- 
fication of  this  required  bacterial  standard  in  proportion  to  the  change 
in  fat. 

As  to  labeling: 

All  milk  should  be  labeled  and  marked  with  the  grade  in  which  it  is 
to  be  sold.  .  .  .  All  milk  should  be  dated  uniformly  with  the  date  of 
delivery  to  the  consumer.  .  .  .  The  stamping  on  the  label  of  the  day 
of  the  week  is  sufficient  for  dating. 


Caps  and  labels  should  state  whether  milk  is  raw  or  pasteurized. 
The  latter  designating  the  grade  to  which  milk  belongs  shall  be  con- 
spicuously displayed  on  the  caps  of  bottles  or  the  labels  on  cans. 

As  to  licensing  of  dealers: 

A  dealer  shall  be  required  to  have  a  permit  or  license  to  sell  an}-  grade 
or  class  of  milk  and  to  use  a  label  for  such  class  or  grade.  Such  permit 
or  license  shall  be  revoked  and  the  use  of  the  label  forbidden  when  the 
local  health  authorities  shall  determine  that  the  milk  is  not  in  the  class 
or  grade  designated. 

^  The  Department  of  Health  of  New  York  City,  since  Nov.  i,  1913, 
has  graded  cream  into  two  grades,  A  and  B,  each  of  which  is  further 
subdivided  into  Raw  and  Pasteurized.  These  are  based  upon  the 
corresponding  grades  in  the  milk  classification  of  that  city.  The 
bacterial  standard  for  Grade  A  is  100,000  per  cc,  while  Grade  B  is  not 
to  contain  "  an  excessive  number  of  bacteria  "  when  delivered.  Speci- 
fications are  laid  down  relative  to  pasteurization,  deliver^'  and  labeling. 
(Weekly  Bull,  N.  Y.  City  Dept.  of  Health,  Sept.  13,  1913;  quoted  in 
Am.  Jour.  Pub.  Health,  1913,  vol.  HI,  no.  11,  p.  1243.) 


366  A   MANUAL   FOR   HEALTH   OFFICERS 

Under  the  head  of  pasteurization  the  Commission  pre- 
scribes the  precautions  which  we  ha\e  already  mentioned 
under  cautions  as  to  expert  management  and  official  super- 
vision. The  views  of  the  Commission  on  the  necessity  for 
pasteurization  of  all  grades  of  milk  with  the  possible  ex- 
ception of  the  very  highest  have  also  already  been  set  forth. 
The  prescription  that  pasteurized  milk  "shall  be  cooled 
immediately  to  50°  F.  or  below  and  kept  at  or  below  that 
temperature"  should  be  noted. 

An  important  portion  of  the  report  covers  the  subject  of 
bacterial  and  chemical  standards.  The  recommendations 
relating  to  raw  and  pasteurized  milk  arc  as  follows: 

Raw  Milk.  —  Not  more  than  100,000  bacteria  per  cubic 
centimeter.  Not  less  than  3.25  per  cent  milk  fat.  Not 
less  than  8.5  per  cent  solids  not  fat. 

Pasteurized  Milk.  —  Not  more  than  1,000,000  bacteria 
per  cubic  centimeter  before  pasteurization,  nor  over  50,000 
when  delivered  to  the  consumer.  Standards  for  milk  fat 
and  solids  same  as  above. 

(For  standards  for  raw  and  pasteurized  cream  and  for 
skim  milk  see  Appendix  B.) 

The  temperature  standard  for  the  handling  of  raw  milk 
and  for  milk  after  pasteurization  is  50°  F. ;  for  milk  before 
pasteurization  60  degrees. 

The  "Standard  Rules  for  the  Production,  Handling  and 
Distribution  of  Milk"  formulated  by  the  Commission  are 
given  in  full  In  Appendix  B,  to  which  the  reader  is  referred 
for  further  details. 

Certified  Milk.  —  The  term  "certified"  can  only  be 
properly  applied  to  milk  produced  under  specially  strict 
conditions  laid  down  by  a  duly  organized  medical  milk 
commission.  Such  commissions  may  be  formed  according 
to  law  in  most  States  (the  term  "certified"  being  protected) 
and  enter  into  agreement  with  the  dairyman  concerned, 
according  to  which  he  agrees  to  fulfill  the  requirements  and 
the  commission  to  certify  the  milk.     The  commission  has 


MILK   ANn   OTHER   FOOD   SUJ'I'LIES  367 

no  connection  with  tlu;  commercial  side  of  tiie  matter  hut 
simply  lends  its  authorization  in  order  that  a  specially  high 
grade  of  milk  suitable  for  the  use  of  infants  and  invalids  may 
be  produced.  The  organization  ancl  methfxls  of  medical 
milk  commissions  have  been  standardized  by  the  American 
Association  of  Medical  Milk  Commissions,  and  no  com- 
mission should  be  considered  as  certifying  milk  that  does 
not  conform  to  the  standards  adopted  from  time  to  time  by 
the  Association.^  Certified  milk  obviously  constitutes  a 
special  class  in  Grade  A  of  the  system  just  described.  It 
forms  but  a  very  small  part  of  the  milk  supply  of  any 
community. 

Special  Milk  Supplies.  —  A  special  watch  should  be 
kept  over  the  milk  supplied  to  hospitals  and  other  institu- 
tions —  especially  those  for  children  —  to  school  lunches, 
and  the  like.  Usually  such  milk  is  delivered  in  bulk  in  cans 
by  special  contract  and  it  is  likely  to  be  overlooked  in  ex- 
aminations of  the  general  market  supplies.  It  should,  of 
course,  conform  to  the  same  conditions  as  milk  on  the  open 
market,  the  dealer  should  be  subject  to  the  license  require- 
ment, any  grading  system  should  apply,  etc.  These  re- 
marks apply  also  to  the  milk  served  in  restaurants,  lunch 
rooms,  cafes,  hotels  and  the  like.  The  milk  supplied  at 
milk  stations  is  of  course  of  special  importance,  should  be 
of  Grade  A  and  might  well  be  pasteurized. 

The  sale  of  milk  in  stores  should  receive  special  attention, 
through  both  inspection  and  laboratory  examination,  being 
very  frequently  exposed  to  deterioration  and  contamina- 
tion.    (See  page  381.) 

^  Further  information  as  to  the  organization  and  standards  of 
medical  commissions  may  be  obtained  from  the  Secretary  of  the  Asso- 
ciation: Dr.  Otto  P.  Geier,  124  Garfield  Place,  Cincinnati,  Ohio.  The 
regulations  for  the  production  of  certified  milk,  revised  to  May  i,  191 2, 
were  published  in  U.  S.  Pub.  Health  Rpts.  for  June  14,  1912. 


368  A  MANUAL   FOR   HEALTH  OFFICERS 

MILK  AND    COMMUNICABLE  DISEASE 

The  dangers  from  milk  in  the  spread  of  communicable 
disease  have  already  been  indicated  in  Chapter  I.  Under 
the  head  of  epidemiology  an  account  was  given  of  the  many 
ways  in  which  milk  may  become  infected  at  the  various 
stages  in  production  and  handling.  The  rules  to  prevent 
infection  through  milk  bottles  left  at  houses  where  a  case 
exists  were  given  under  the  head  of  isolation  regulations 
(page  127). 

Milk  infection  is  most  to  be  apprehended  from  cases  of 
communicable  disease  —  frequently  missed  (or  even  con- 
cealed) or  carrier  cases  —  among  persons  in  any  way  con- 
nected with  the  handling  of  milk  or  milk  utensils.^  Even 
drivers,  through  handling  bottles  and  other  containers,  are 
potential  infecting  agents.  Farm  water  supplies  as  possible 
sources  of  infection  will  be  taken  up  in  the  next  chapter. 
Prompt  report  of  infection  among  persons  connected  in 
any  way  with  milk  supplies  should  be  required  of  phy- 
sicians to  be  made  (by  telephone  or  telegraph  followed 
by  writing)  to  the  state  department  of  health  or  to  the 
health  department  of  the  town  to  which  the  milk  is  sent, 
as  well  as  to  that  in  whose  district  it  occurs.  Cases  in  the 
families  of  such  persons  should  also  be  included  under  this 
regulation  on  account  of  the  danger  of  the  employee  de- 
veloping an  active  or  carrier  case  of  tlie  disease.  Each  case 
should  be  dealt  with  promptly  and  firmly  on  its  merits,  on 
pain  of  exclusion  of  the  milk  supply.  If  there  is  reason  to 
believe  that  the  supply  is  infected  it  should  be  cut  off  until 
matters  have  been  so  arranged  that  there  is  no  possible  con- 
nection between  patient  and  nurse  and  milk  supply.  The 
patient  should,  if  possible,  be  removed  from  premises  where 
milk  is  handled;   but  if  not,  nothing  short  of  complete  and 

'  The  Montclair,  N.  J.,  Board  of  Health  has  recently  adopted  a  re- 
quirement that  such  persons  file  medical  certificates  of  freedom  from 
evidence  of  communicable  disease  every  three  months.  The  aim  in  this 
case  is  to  obtain  a  high-grade  public  supply  of  raw  milk. 


MILK   AND   OTHKR    V()()\)    SUIMMJIIS  369 

positive  isolation  of  patient  and  nurse  (fiic  lallcr  to  he 
thoroughly  competent),  with  entirely  satisfactory  rlisinfec- 
tion  measures,  should  be  permitted.  Then,  jjefore  re- 
sumption of  business  is  allowed,  all  bottles,  cans  and 
other  apparatus  and  utensils  should  be  sterilized  by  steam 
or  boiling  under  official  supervision.  The  possibility  of 
carriers,  incipient  and  mild  cases  produced  by  contact 
with  the  original  case  must  not  be  overlooked;  in  typhoid 
fever,  known  and  suspected  contacts  concerned  in  the 
handling  of  the  supply  should  be  kept  under  more  or  less 
close  observation,  and  cases  of  sickness  should  be  isolated 
and  the  blood  examined  (see  page  196  f.);  in  diphtheria, 
cultures  should  be  taken  for  the  same  purpose  (two  con- 
secutive negatives  to  be  required  of  suspicious  cases).  It 
is  obvious  that  searching  precautions  are  worth  while  when 
there  is  question  of  protecting  a  milk  supply  at  the  source. 
Detailed  rules  cannot  be  laid  down;  each  case  must  be 
dealt  with  on  its  merits  and  the  principles  involved. 

All  of  this  simply  emphasizes  the  remarks  made  earlier 
as  to  the  desirability  of  protecting  milk  supplies  —  es- 
pecially the  larger  ones  —  by  pasteurization.  Where  ade- 
quate routine  pasteurization  of  milk  is  practiced,  with 
sterilization  of  bottles  and  other  containers,  utensils  and 
apparatus,  and  with  proper  mechanical  handling,  the 
chances  of  infection  are  practically  eliminated.  Inspec- 
tions and  physician's  reports  are  not  complete  safeguards, 
and  infection  has  been  known  (as  in  recently  reported 
epidemics)  to  be  possible  under  the  best  apparent  con- 
ditions of  cleanliness  as  commonly  understood. 

METHODS    OF    CONTROL 

Milk  regulations  are  enforced,  on  the  one  hand,  through 
inspection  of  equipments  and  methods,  and,  on  the  other, 
through  laboratory  tests,  bacteriological  and  chemical,  of 
the  product.  The  two  forms  of  supervision  supplement 
each  other,  the  laboratory  methods  pointing  out  deficien- 


37©  A  MANUAL   FOR   HEALTH  OFFICERS 

cies  which  inspection  cannot  practically  detect,  while 
inspection  searches  out  and  applies  the  corresponding 
remedies. 

/.    CONTROL  BY  INSPECTION 

Milk  supplies  require  inspection  at  the  J-ollowifig  points: 

1.  At  the  dairy  farm. 

2.  At  the  bottling  establishment. 

3.  In  transportation,  whether  by  wagon  in  the  country, 
by  railroad,  by  wagon  or  otherwise  in  the  city. 

4.  While  on  sale,  from  wagons,  stores,  etc. 

To  this  schedule  we  may  add  the  care  of  milk  in  the  home, 
the  final  and  important  matter  but  necessarily  left  to  the 
consumer. 

Such  inspections  include  not  only  milk  and  its  products 
but  also  the  empty  containers  on  their  way  back  and  forth. 

The  proper  inspection  of  the  various  processes  of  milk 
production  and  handling  requires  a  knowledge  of  trade 
methods  as  well  as  of  sanitary  requirements,  an  under- 
standing of  the  point  of  view  of  the  dairyman  and  dealer 
as  well  as  that  of  the  health  offtcial  and  sanitarian.  The 
efficient  milk  inspector  should  be  an  adviser  and  instructor 
of  the  dairyman  as  well  as  a  monitor. 

Even  in  small  towns  milk  inspection  should  constitute 
a  special  and  separate  branch  of  the  work  of  the  depart- 
ment of  health  presided  over  by  a  milk  inspector.  Milk 
inspection  involves  so  many  details  and  demands  so  inti- 
mate a  familiarity  with  the  details  of  the  milk  industry  that 
it  cannot  be  adequately  carried  on  by  halfway  methods. 
In  the  small  town  the  milk  inspector  may  make  all  the 
inspections  necessary  ^  —  farms,  bottling  establishments, 
stores,  etc.  —  and  frequently  collect  samples  and  perform 
laboratory  analyses.  Where  a  town  is  unable  to  support  a 
whole-time  expert  inspector  and  a  milk  laboratory  of  its 
own,  the  solution  may  be  to  cooperate  with  a  neighboring 
1  Cf.,  however,  remarks  on  state  inspection,  p.  395. 


MILK  AND   OTHER   FOOD   SUPPLIES  371 

town  or  towns  in  the  maintenance  of  a  joint  inspection  or  at 
least  of  a  joint  laboratory;  thus  efficient  work  which  would 
otherwise  be  impossible  may  be  carried  cjn  without  ^n-at 
expenditure.  The  possibilities  in  slate  inspection  will  be 
discussed  in  a  later  paragraph. 

Milk  inspectors  should  preferably  be  graduates  of  agri- 
cultural or  dairying  schools.  This,  however,  is  not  essen- 
tial, and  an  intelligent  man  interested  in  the  work  will  soon 
pick  up  the  practical  points  and  with  the  aid  of  the  score- 
card  (which  will  be  described  presently)  will  be  able  to  per- 
form accurate  and  effective  inspections.  Knowledge  of 
veterinary  medicine  is  not  essential,  for  the  board  of  health 
may  (the  best  plan)  appoint  its  own  veterinarian,  or,  if  not 
able  to  do  this,  require  the  written  certificates  of  reputable 
veterinarians  as  to  the  health  of  herds  (see  requirements 
of  Commission  on  Milk  Standards).  For  laboratory  work, 
on  the  other  hand,  adequate  technical  training  is  necessary. 

The  Score-card  System  is  now  applied  very  generally 
by  efficient  health  authorities  to  the  inspection  of  dairy 
farms,  bottling  establishments,  creameries  and  stores 
handling  milk  in  bulk.  There  is  no  question  that  this  is 
the  best  means  of  making  thorough  inspections,  both  for 
the  expert  and  for  the  inexperienced  inspector.  In  dis- 
cussing its  advantages  to  the  health  department,  the  De- 
partment of  Agriculture  experts,  whose  cards  are  used  as 
standards,  remark: 

The  score-card  system  is  of  particular  value  to  the  inspector  in 
pointing  out  conditions,  thus  making  it  impossible  to  overlook  any 
point  of  importance.  All  these  items  are  kept  in  a  permanent  record 
by  this  system  and  comparisons  can  readily  be  made.  .  .   . 

Where  the  score-card  system  is  in  use  there  is  frequently  more  or 
less  competition  for  high  scores.  No  dairyman  wants  the  name  of 
being  the  poorest.  This  competition  makes  it  easier  for  the  inspector 
to  improve  conditions,  as  his  suggestions  are  readily  heeded.^ 

^  Lane  and  Whittaker,  "  The  Score-card  System  of  Dairy  Inspec- 
tion," U.  S.  Dept.  of  Agric,  Bureau  of  Animal  Industry'  Circular  139, 
1909.     Cards   for  scoring   dairy   farms,   city   milk   plants  and    stores 


372  A  MANUAL  FOR   HEALTH   OFFICERS 

From  the  standpoint  of  the  producer  the  system  has  marked  advan- 
tages. He  can  feel  that  he  has  received  an  accurate  and  impartial  score, 
for  with  everything  written  down  in  black  and  white  the  opportunities 
for  error  and  favoritism  are  small.  If  the  inspector  has  tact  and  talks 
over  with  the  dairyman  the  various  ratings  on  the  card  and  the  reason 
for  the  score  he  makes,  the  dairyman  becomes  interested  and  is  helped 
by  means  of  the  card.  If  the  inspector  has  sufficient  skill  to  make  not 
only  a  reasonably  accurate  score  but  also  some  suggestions,  he  becomes 
a  friend  and  helper  of  the  dairyman  and  his  visits  are  looked  forward  to 
with  satisfaction.  The  score-card  system  is  simple  and  easily  under- 
stood. In  some  places  the  health  authorities  have  made  too  many  and 
too  complex  regulations.  They  have  studied  what  is  necessary  in  the 
production  of  sanitary  milk  and  then  have  embodied  these  essentials  in 
a  dairy  law.  If  such  a  code  were  literally  obeyed  it  would  result  in 
perfect  milk,  which  is  impossible,  and  the  health  authorities  know  that 
the  law  will  not  and  cannot  be  enforced.  The  dairyman,  however,  looks 
at  the  formidable  code  of  fifteen  to  twenty  pages  with  feelings  of  per- 
plexity and  irritation,  knowing  that  he  cannot  comply  with  its  require- 
ments. Rating  a  dairy  according  to  its  merits  does  away  with  this 
irritation,  and  as  the  dairyman  makes  improvements  he  has  the  satis- 
faction of  seeing  his  score  increase.  The  score  card  protects  the  dairy- 
man from  the  faddist  who  can  see  nothing  but  the  tuberculin  test,  a 
cement  floor  or  white  milking  suits.' 

The  score-card  system  makes  it  a  simple  matter  to  es- 
tablish certain  inspection  standards  for  different  grades  of 
milk  (cf.  Appendix  B,  Standard  Rules  of  the  Commission 
on  Milk  Standards). 

There  is  abundant  proof  that  the  score-card  system  brings 
immediate  and  permanent  results  wherever  it  is  put  in 
practice.  Magruder,  in  a  paper  which  we  have  already 
quoted,  cites  the  example  of  Richmond,  Va.: 

handling  bulk  milk  have  been  adopted  by  the  Department  of  Agricul- 
ture and  are  recommended  for  adoption  by  local  health  authorities. 
For  copies  of  the  cards  (which  cannot  conveniently  be  reproduced  here), 
detailed  directions,  and  advice  as  to  their  use,  apply  to  the  Bureau  of 
Animal  Industry,  Washington,  D.  C. 

'  Whittaker,  "  The  Score-card  System  of  Dairy  Inspection  from  the 
National  Standpoint,"  Jour.  Am.  Pub.  Health  Assn.,  191 1,  vol.  I, 
no.  9,  p.  647. 


MILK   AND    DTIIKR    FOOD    SUIM'I.IKS  373 

The  experience  of  Richmond,  Vu.,  wilh  insijcction  has  been  most 
gratifying.  Ins|)ection  began  in  May,  1907.  The  average  rating  of  the 
farmers  was  41.5  out  of  a  i)ossii)lc  lOO.  But  15  per  cent  of  the  dairies 
scored  above  60.  In  December,  191 1,  not  one  was  rated  below  70.  Of 
all  supplying  Richmond,  67.4  were  rated  between  80  and  90;  5.5  per  cent 
were  rated  above  90.     In  his  report  for  191 1  the  Health  Officer  says: 

"  The  insi)ector  has  been  enabled  to  give  sound  practical  advice  to 
our  dairymen,  thereby  assisting  them  in  many  ways.  .  .  .  Practically 
all  our  dairymen  have  come  to  regard  him  as  a  real  friend  and  hclj;cr." 

Much  improvement  has  also  been  obtained  at  Washing- 
ton, D.  C,  where  the  score-card  was  first  used,  under  Health 
Officer  Woodward,  and  many  other  places. 

There  is,  however,  a  caution  which  should  be  emphasized 
in  connection  with  the  use  of  scores  for  administrative  pur- 
poses. It  must  be  remembered  that  a  score  represents 
simply  the  general  condition  and  for  this  reason  does  not 
always  indicate  the  importance  of  certain  particulars  which, 
if  deficient,  may  assume  a  greater  importance  than  would 
be  indicated  by  the  regular  deduction  from  the  score.  This, 
it  is  true,  is  partly  provided  in  the  use  of  the  card,  by  making 
special  arbitrary  deductions  from  the  score;  nevertheless 
certain  specific  minimimi  requirements  (such,  for  example, 
as  to  temperature)  as  well  as  a  minimum  total  score  should  be 
laid  down  and  enforced  by  ordinance.  For  these  the  Rules 
already  referred  to  (Appendix  B)  may  be  used  as  the  basis. 
In  fact,  with  such  minimum  requirements  the  use  of  the 
score-card  might  possibly  be  done  away  with,  but  for  the 
present,  in  most  places,  a  combination  of  the  two  methods 
of  regulation  is  perhaps  most  practicable,  —  the  one  cover- 
ing the  general  condition,  the  other  particular  points. 

I.  Dairy  Farms.  —  The  Department  of  Agriculture 
score-card  ^  may  be  taken  as  an  illustration,  in  connection 
with  the  Rules  of  the  Commission  on  Milk  Standards 
(Appendix  B)  of  dairy  farm  inspection.  Minimum  re- 
quirements  should,    as   above   suggested,    be   adopted   in 

^  For  copies  of  card,  detailed  directions  and  advice  apply  to  U.  S. 
Bureau  of  Animal  Industry,  Kept,  of  Agriculture,  Washington,  D.  C 


374  A  MANUAL   FOR  HEALTH  OFFICERS 

accordance  with  the  Rules.  Special  attention  should  be 
paid  to  the  important  and  essential  points,  such  as  cleanli- 
ness of  cows,  utensils  and  methods,  and  cooling.  Utensils 
and  containers  should  be  kept  scrupulously  clean  and  should 
be  sterilized  by  scalding  if  not  with  live  steam.  The  use  of 
small-mouth  milking  pails  is  an  important  point;  it  has 
been  shown  that  through  their  use  90  per  cent  of  the  bac- 
teria getting  into  milk  at  the  time  of  milking  can  be  elimi- 
nated (experiments  by  Stocking).  Hooded  pails  cost  little 
more  than  ordinary  ones  and  dairymen  readily  become 
accustomed  to  their  use.  A  frequent  trouble  is  the  use  of 
cheap  utensils,  which  deteriorate  and  accumulate  dirt  and 
decaying  milk  solids  in  cracks  and  holes. 

Farm  water  supplies  should  be  carefully  looked  after, 
for  it  is  frequently  not  at  all  certain  that  milk  utensils  are 
properly  sterilized,  and  they  may  of  course  be  contami- 
nated by  the  washing  water.  It  is  possible  also  that  cows 
may,  after  wading  in  polluted  streams,  infect  milk  mechan- 
ically through  the  water  remaining  on  their  udders  and 
other  parts. 

In  making  recommendations  to  the  dairyman  infinitely 
more  can  be  accomplished  by  frequent  visits,  taking  up  a 
few  important  points  with  him  each  time,  and  when  these 
have  been  accomplished  passing  on  to  the  less  essential, 
than  by  sweeping  visits  months  apart  in  which  so  many 
recommendations  are  made  that  confusion  and  discourage- 
ment are  created.  In  point  of  fact,  annual,  or  even  semi- 
annual, visits  accomplish  practically  nothing;  frequent 
reins pections  are  absolutely  necessary,  the  more  frequent 
according  to  the  requirements  of  the  case.  This  applies  to 
all  kinds  of  milk  inspections.  A  number  of  departments 
make  their  regular  dairy  inspections  once  a  month.  At  the 
same  time,  where  objectionable  conditions  are  suspected, 
it  may  be  desirable  to  inspect  at  irregular  and  unexpected 
times.  When  a  farm  is  revisited  frequently  the  score  can 
readily  be  revised  (for  certain  of  the  items  will  remain  un- 


MILK   ANI>   (/IHKR    FOOD   SUPPLIKS  375 

changed  from  time  to  time),  or  supplementary  rejjorts  can 
be  made  on  special  conditions. 

It  is  recommended  that  the  insfKx:tion  of  dairies  be  sys- 
tematized, so  as  to  insure  adecjuate  inspection  and  to 
facilitate  laying  out  routes.  A  plan  has  been  suggested  by 
Lane  and  Whittaker  (Circular  139,  Bureau  of  Animal  In- 
dustry) which  is  readily  applicable  to  places  of  all  sizes. 
Its  essentials  are:  a  large  rhap  on  which  are  indicated  the 
locations  of  dairies  by  means  of  tacks,  each  having  a  number 
on  its  head  representing  the  dairyman's  permit  number 
(the  tacks  may  be  of  different  colors  to  distinguish  between 
different  grades),  and  an  index  list  in  connection  with  the 
map,  showing  each  dairyman's  name,  permit  number  and 
the  latest  scores  for  each.  Where  the  milk  from  two  or  more 
dairies  is  collected  by  one  dealer  these  should  be  grouped 
together  and  their  average  given  in  the  list.  Map  and  list 
may  be  placed  in  the  health  office  so  that  both  dairymen 
and  public  may  readily  consult  them.  This  tends  to  produce 
improvement  by  dairymen  and  enlightenment  of  citizens. 

For  remarks  on  number  of  inspectors  required,  etc.,  see 
later  under  Organization. 

2.  Shipping  and  Bottling  Establishments.  —  Milk  after 
production  is  usually  either  bottled  on  the  farm  and  sold 
by  the  producer,  or  it  is  collected  from  one  or  more 
farms  by  a  dealer  who  bottles  it  either  in  the  country  or  in 
the  city.  Some  milk,  of  course,  is  not  bottled  at  all,  but  is 
peddled  from  cans  either  from  wagon  or  from  store.  The 
tendency  is  more  and  more  toward  the  handling  of  milk 
by  large  dealers  who  collect  from  numbers  of  separate 
dairies  on  a  wholesale  scale.  Plants  or  depots  where  milk 
is  collected  in  the  country  districts,  frequently  called 
"creameries,"  are  often  many  miles  away,  so  that  railroad 
transportation  to  the  town  or  city  becomes  necessary. 
Whether  milk  is  collected  at  a  point  in  the  country-  or  city, 
whether  it  is  bottled  in  the  country  or  city,  whether  in  a 
plant  handling  hundreds  of  quarts  a  day  or  in  a  milk  house 


376  A  MANUAL   FOR   HEALTH  OI-ITCERS 

handling  only  a  few  dozen,  the  principles  of  inspection 
are  the  same,  and  are  in  fact  precisely  those  which  govern 
dairy  inspection:  Milk  should  he  exposed  to  the  air  as  little 
as  possible,  and  the  air  should  be  pure;  it  should  not  be 
handled  in  unclean  utensils  or  apparatus,  and  it  should 
always  be  kept  cool.  The  same  considerations  also  apply 
to  pasteurizing  plants,  with  the  additional  attention  re- 
quired to  the  process  itself. 

The  score-card^  of  the  Department  of  Agriculture  for 
"sanitary  inspection  of  city  milk  plants"  may  readily  be 
applied  or  adapted  to  any  establishment  handling  milk, 
large  or  small,  in  the  country  as  well  as  in  the  city.  When 
milk  is  bottled  in  a  milk  house  on  a  dairy  farm,  the  same 
should  be  considered  as  a  bottling  establishment  as  well 
as  a  milk  house  and  the  corresponding  regulations  should 
apply  to  it.  The  score-card  favors  plants  which  have  sepa- 
rate rooms  for  the  various  processes,  full  sets  of  mechanical 
devices  (for  bottling,  etc.),  and  other  conveniencies;  such 
equipment  makes  for  sanitation  as  well  as  convenience. 
At  the  same  time  it  is  possible  for  the  smaller  establish- 
ments, by  installing  proper  appliances  and  operating  accord- 
ing to  requirements,  to  come  up  to  a  proper  standard. 

As  with  dairy  farms  it  is  very  desirable  to  establish  for 
milk  receiving  and  bottling  plants  certain  minimum  re- 
quirements. Some  such  requirements  have  been  framed  by 
the  Commission  on  Milk  Standards  (see  Appendix  B).  The 
following,  in  more  detail,  are  also  suggestive.  Such  mini- 
mum requirements  should  of  course  be  thoroughly  reason- 
able and  enforceable  —  virtues  not  always  found  in  milk 
ordinances  —  and  should  apply  equally  to  large  and  to  small 
establishments.  It  is  perfectly  feasible  to  maintain  such  re- 
quirements in  combination  with  the  scoring  system,  making 
a  certain  minimum  score  one  of  the  requirements.  Thus 
both  general  and  specific  conditions  will  be  covered. 

*  For  copies  of  card,  detailed  directions  and  advice  apply  to  the 
Bureau  of  Animal  Industry,  Dept.  of  Agriculture,  Washington,  D.  C. 


MILK   AND   OTIIKR    FOOD    SUF'F'LIKS  377 

Be  it  enacted  by  the  Board  of  Health  of  the  [town,  city,  village  J  of 
,  as  follows: 

The  term  "  milk-bottling  establishment  "  or  "  establishment,"  as 
hereinafter  used,  shall  be  held  to  include  any  and  every  building,  or 
part  of  a  building,  wherever  located,  in  which  milk  is  bottled  for  sale 

or  distribution  in  the  [town,  city,  village]  of  .     The  term  "  bottling 

room  "  shall  be  held  to  apply  to  any  room,  or  part  of  a  building,  in  which 
milk  is  exposed  or  bottled,  and  the  term  "  washing  room  "  to  any  room, 
or  part  of  a  building,  in  which  any  containers,  apparatus  or  utensils, 
used  in  the  handling  of  milk,  are  cleansed  or  otherwise  treated.  The 
following  rules  shall  apply  to  all  such  milk-bottling  establishments; 
and  no  milk  which  has  been  bottled,  handled  or  stored  in  non-compli- 
ance with  or  violation  of  any  of  said  rules  shall  be  sold,  held  or  offered 

for  sale,  or  delivered  in  the  [town,  city,  village]  of ,  under  a  penalty 

of  twenty-five  dollars  for  each  and  every  offense. 

1.  No  such  establishment  shall  be  located  within  100  feet  of  any  hog 
pen,  manure  pile,  privy  vault  or  other  source  of  contamination. 

2.  Water  used  for  washing  bottles  and  utensils  shall  be  obtained 
from  a  source  subject  to  approval  by  this  Board. 

3.  Every  privy  vault  located  on  any  premises  where  milk  is  bottled 
shall  be  so  constructed  that  the  contents  shall  be  inacessible  to  flies,  and 
every  such  privy  vault  shall  be  kept  at  all  times  in  a  sanitary  condition. 

4.  BottHng  and  washing  rooms  shall  conform  to  the  following 
requirements: 

(a)  Floors  to  be  water-tight,  constructed  of  cement,  concrete  or 
other  non-absorbent  material,  and  properly  drained  to  a  point  or 
points  at  which  drainage  is  disposed  of. 

(b)  Walls  and  ceilings  to  be  smooth  and  kept  well  painted  or  lime- 
washed. 

(c)  Adequate  natural  or  artificial  light  to  be  provided. 
{d)    Adequate  ventilation  to  be  provided. 

(e)  Rooms  to  be  thoroughly  screened  against  flies  from  April  first 
to  November  first  of  each  year. 

5.  Drainage  shall  not  be  permitted  to  flow  into  or  upon  the  ground 
underneath  the  establishment  or  within  100  feet  of  the  same.  If 
drainage  is  collected  in  a  cesspool  or  other  receptacle,  the  same  shall  be 
water-tight  and  shall  be  kept  in  a  sanitary  condition. 

6.  Non-employees  shall  be  excluded  at  all  times  from  bottling  and 
washing  rooms. 

7.  Milk  on  reaching  the  establishment  shall  be  immediately  cooled 
to  a  temperature  not  exceeding  50°  F.  (if  such  cooling  has  not  already 
taken  place),  and  shall  be  thereafter  maintained  at  such  a  tempera- 
ture.    Cooling  tanks  shall  be  constructed  of  smooth,  water-tight,  non- 


378  A   MANUAL   FOR   HEALTH   OFFICERS 

absorbent  material,  and  the  water  in  such  tanks  shall  be  changed  at 
least  once  a  day  during  the  months  of  May,  June,  July,  August  and 
September,  and  at  least  twice  a  week  during  the  remainder  of  the 
year. 

8.  All  bottles  and  other  containers,  apparatus  and  utensils,  used  in 
handling  milk,  shall,  after  use  and  before  being  re-filled  or  re-used,  be 
thoroughly  cleansed  and  sterilized. 

9.  Adequate  lavatory  facilities  for  employees  shall  be  provided, 
separate  and  distinct  from  apparatus  used  for  handling  milk  or  treating 
milk  utensils.  All  employees  engaged  in  bottling  and  washing  rooms 
shall,  before  beginning  work  and  after  visiting  the  toilet,  wash  their 
hands  thoroughly  with  clean  water  and  soap. 

10.  No  bottling  or  washing  room  shall  be  used  as  a  living  or  sleeping 
room  or  be  directly  connected  with  such  room  or  be  used  for  any  other 
purpose  other  than  the  storage  or  handling  of  milk  and  milk  utensils. 

11.  No  person  afTected  with  typhoid  fever,  dysentery,  scarlet  fever, 
diphtheria,  tuberculosis  or  any  other  communicable  disease,  which  may 
be  declared  by  the  Board  to  be  included  in  this  regulation,  shall  be 
employed  in  any  milk-bottling  establishment;  nor  shall  any  member  of 
the  family  or  household  of  any  such  person  be  so  employed,  unless  by 
permission  of  this  Board. 

12.  All  milk  utensils  and  apparatus  shall  be  of  such  construction  as 
to  be  readily  cleansed  and  shall  be  kept  in  good  repair  and  free  from 
rust. 

13.  Bottle-caps  shall  be  kept  in  a  clean,  dust-proof  container. 

14.  Bottling  and  washing  rooms  and  all  parts  thereof  shall  be  kept 
clean  and  free  from  offensive  odor.  Dirt,  dust,  rubbish,  clothing,  all 
articles  not  used  in  the  handling  of  milk  and  domestic  animals  shall  not 
be  permitted  in  such  rooms. 

15.  All  employees  in  bottling  and  washing  rooms  shall  keep  them- 
selves and  clothing  in  a  clean  condition.  Clean  aprons  or  suits  used  for 
no  other  purpose  shall  be  worn  by  such  employees  while  in  the  perform- 
ance of  their  duties. 

16.  No  spitting  or  smoking  shall  be  permitted  in  bottling  and  wash- 
ing rooms. 

17.  A  copy  of  the  above  rules,  furnished  by  the  Board  of  Health, 
shall  be  posted  in  a  conspicuous  place  in  each  milk-bottling  establish- 
ment. 

18.  No  milk  shall  be  bottled  except  in  an  establishment  in  which 
all  of  the  foregoing  regulations  are  complied  with,  and  at  no  time  and 
in  no  place  shall  milk  be  exposed  to  contamination  by  dust,  dirt,  flies, 
communicable  disease  or  any  other  act  or  thing  injurious  to  health.^ 

'  Ordinance  adopted  in  Orange,  N.  J.,  1913. 


MILK   AND    OrilKK    I(K)I>    SIJI'I'IJKS  .^79 

It  would  be  well  to  re(|uire  that  such  conditions  be  fiilfillcfl 
before  a  license  is  issued  to  the  dealer,  reserving  the  right 
to  revoke  the  license  in  case  there  is  failure  to  live  up  to  the 
ordinance.  A  form  of  inspection  card  based  on  such  re- 
quirements could  readily  be  made  up,  differing  from  a  score- 
card  in  taking  account  simply  of  conditions  all  of  which 
would  be  required. 

The  requirement  (8)  of  sterilization  practically  means  the 
installation  of  a  steam  boiler  and  the  necessary  apparatus 
in  every  establishment  —  a  steam  chamber,  and  jets  for 
the  treatment  of  cans,  "fillers,"  etc.  There  are  a  number 
of  installations  on  the  market  for  the  purpose,  A  simple 
apparatus  is  not  an  excessive  requirement  for  any  bottling 
establishment  which  pretends  to  enter  seriously  into  the 
important  business  of  handling  milk,  and  this  is  the  only 
kind  which  should  be  permitted  to  operate.  The  effects 
of  the  best  apparatus,  however,  may  be  lost  through  mis- 
management, and  inspection  should  insure  that  routine 
sterilization  is  complete,  also  that  there  is  no  contamina- 
tion of  bottles  or  utensils  after  sterilization  and  before  use. 

The  inspector  of  establishments  handling  milk  should 
note  whether  it  Is  allowed  to  remain  in  uncovered  tanks, 
vats,  bottling  machines,  cans  or  bottles  any  longer  than 
is  absolutely  necessary  before  placing  in  storage;  whether 
coolers,  receiving  tanks  and  the  like  are  protected  by 
cheese-cloth  or  other  covers  when  not  located  in  specially 
constructed  sanitary  rooms;  and  whether  milk  is  passed 
through  piping  that  cannot  be  taken  apart  and  properly 
cleaned. 

The  health  of  employees  is  a  most  important  considera- 
tion which  the  inspector  should  ahvaj-s  bear  in  mind,  being 
on  the  lookout  for  positive  or  suspected  cases  of  commu- 
nicable disease. 

3.  Milk  in  Transit.  — The  inspection  of  milk  in  transit 
at  various  stages  is  an  important  consideration  frequently 
neglected.     In  country  districts  it  may  be  transported  in  an 


380  A  MANUAL  FOR   HEALTH   OFFICERS 

open  farm  wagon  in  warm  weather  willi  liule  or  no  pro- 
tection from  the  summer  warmth;  on  the  railroads  it 
frequently  is  carried  in  cars  which  have  no  refrigeration 
facilities;  in  the  town,  on  its  way  from  railroad  station  to 
bottling  plant  it  may  suffer  a  further  rise  in  temperature. 
At  all  stages  it  may  be  left  standing  on  station  platforms, 
perhaps  in  hot  sun,  and  other  places  where  it  is  insufficiently 
protected  from  warmth  and  contamination  by  meddlers. 

Inspection  of  transit  conditions  relates  chiefly  to  tempera- 
ture and  to  seeing  that  containers  are  not  sent  back  without 
washing.  The  law  should  prescribe  a  temperature  standard 
for  the  different  grades  of  milk,  60°  F.  being  the  maximum 
allowed  for  any  grade,  with  50  degrees  as  the  maximum 
for  milk  after  pasteurization  (see  Rules,  Appendix  B),  and 
temperatures  should  frequently  be  taken.  The  jacketing 
of  cans  is  by  no  means  always  sufficient  to  keep  down 
temperature,  and  refrigeration  en  route  may  sometimes 
have  to  be  resorted  to,  especially  when  the  initial  tem- 
perature was  not  very  low. 

As  to  the  condition  of  empty  containers,  a  provision 
should  be  adopted  to  the  effect  that  no  such  container  may 
be  placed  in  transportation  without  proper  washing.  This 
provision  does  not  of  course  necessarily  apply  to  milk  bottles 
for  it  is  not  desirable  to  require  householders  to  cleanse 
bottles,  and  if  they  did  so  the  temptation  on  the  part  of  the 
milk  dealer  to  re-fill  the  same  without  sterilization  would  be 
increased.  The  proper  place  for  the  cleansing  of  cans, 
milk  pails,  etc.,  is  the  receiving  or  bottling  plant,  where 
there  are  adequate  washing  facilities  and  where  sterilization 
can  also  be  performed.  It  would  be  well  if  country  cream- 
eries would  adopt  a  rule  requiring  farmers  to  bring  pails 
and  other  utensils,  as  well  as  cans,  to  the  creamery  to  be 
washed  and  sterilized;  this  would  be  an  assurance  that 
these  operations  are  properly  performed  and  a  protection 
against  the  possible  contamination  of  farm  water  sup- 
plies. 


MII.K    AND   O'I'lllik    yOOl)    SUri'lJKS  381 

4.  Milk  on  Sale.  —  Supervision  here  apjjlics  \>(>{\\  lo 
wagons  and  to  stores  anfl  booths. 

In  regard  to  wagons  the  same  i)rincipl(;s  apply  as  to  milk 
in  transportation.  Plenty  of  ice  on  delivery  wagons  in  the 
warmer  months  should  be  the  rule.  Some  milkmen  make 
a  practice  of  filling  bottles  in  their  wagons,  frequently 
using  for  this  purpose  returned  bottles  which  have  not  been 
properly  washed  and  sterilized;  this  should  of  course  be 
strictly  forbidden,  as  well  as  the  practice  of  transferring 
milk  from  can  to  can,  in  delivering  or  otherwise,  on  the 
street.  In  the  same  way  the  peddling  of  "loose"  or  "dip" 
milk  from  wagons  is  objectionable  unless  carried  on  in  a 
closed  wagon  with  special  care. 

The  use  of  milk  tickets  which  are  used  more  than  once 
should  be  forbidden. 

In  regard  to  stores  the  question  is  much  more  difficult. 
In  miany  cases  milk  is  sold  in  stores  as  a  minor  side-line,  or 
merely  as  an  accommodation  to  customers  who  come  pri- 
marily to  buy  groceries,  produce,  etc.  In  such  cases  proper 
care  is  not  likely  to  be  taken  of  it  and  it  is  subject  to  various 
contaminations.  At  the  same  time  the  sale  of  milk  in 
stores,  particularly  "loose"  or  "dip"  milk  in  cans,  is  an 
important  source  of  supply  for  poor  people  who  buy  in 
small  quantities  and  must  therefore  be  regulated  rather 
than  forbidden.  Such  is  the  policy  which  has  been  adopted 
by  active  health  departments.  As  an  indication  of  the 
points  to  be  looked  to  in  such  stores  the  score-card  ^  of  the 
Department  of  Agriculture  may  be  consulted. 

Of  course  where  bottled  milk  is  sold  in  stores  the  only 
requirement  to  be  applied  is  proper  refrigeration,  with  the 
assurance  that  bottles  are  not  opened  and  sold  in  "split" 
quantities. 

Here  again,  as  in  the  inspection  of  dairy  farms  and  re- 
ceiving and  bottling  establishments,  reliance  should  not  be 

^  For  copies  of  card,  detailed  directions  and  ad\-ice  apply  to  the 
Bureau  of  Animal  Industrj-,  Dept.  of  Agriculture,  Washington,  D.  C. 


382  A   MANUAL   FOR   HEALTH   OFFICERS 

placed  upon  the  score  alone,  but  there  should  be  certain 
minimum  requirements,  tlie  character  of  whicli  is  indicated 
by  the  following  regulations  adopted  by  the  Health  De- 
partment of  New  York  City  in  19 13. 

REGULATIONS  FOR  THE  SALE  OF  DIPPED  MILK  AND 
CREAM  IN  STORES 

1.  Milk  or  cream  shall  not  be  stored,  handled  or  sold  in  any  stable, 
or  in  any  room  used  for  cooking  or  domestic  purposes,  or  in  any  room 
which  communicates  directly  with  any  such  stable  or  room,  or  in  any 
room  in  which  there  is  a  water  closet  apartment  or  with  which  a  water 
closet  apartment  communicates,  unless  such  apartment  be  enclosed  by 
a  vestibule,  and  both  apartment  and  vestibule  be  properly  ventilated  to 
the  external  air. 

2.  The  term  "  domestic  purposes  "  shall  be  held  to  apply  to  rooms 
used  for  sleeping  purposes  or  for  cooking  purposes  other  than  the 
preparation  of  the  midday  meal. 

3.  Milk  or  cream  shall  not  be  handled  or  sold  in  any  room  which  is 
unduly  crowded. 

4.  Milk  or  cream  shall  not  be  dipped  from  cans  stored  in  a  room  in 
which  butter  or  cheese  is  manufactured. 

5.  Milk  or  cream  may  be  stored  in  a  cooling  or  refrigerating  room, 
or  ice  chest,  the  construction  of  which  has  been  approved  by  the  depart- 
ment. 

6.  No  milk  or  cream  shall  be  dipped  from  cans  stored  in  a  milk 
booth. 

7.  Milk  shall  be  kept  at  a  temperature  of  50°  F.  or  below  at  all 
times. 

Equipment 

1.  Rooms  in  which  milk  or  cream  is  handled  or  sold  shall  be  well 
lighted. 

2.  The  floors,  walls  and  ceilings  shall  be  smooth,  and  must  be  kept 
clean  and  sanitary. 

3.  All  windows  and  doors  shall  be  properly  screened. 

4.  An  adequate  supply  of  hot  water  shall  be  provided  for  the  washing 
of  utensils. 

5.  A  sufficient  number  of  properly  constructed  ice  tubs,  or  other 
adequate  refrigerating  facilities,  for  cans  of  milk  or  cream  shall  be 
provided. 

6.  All  utensils  used  for  dipped  milk  or  cream  shall  be  of  the  seamless 
sanitary  type,  heavily  tinned. 


MILK   AND   O'J'HKR    FOOD    SUPPLIES  383 

Methods 

1.  No  milk  or  cream  shall  be  dipped  from  cans  stored  in  any  room 
in  which  rubbish  or  dirly  material  is  allowed  to  accumulate,  or  in  which 
there  are  offensive  odors. 

2.  All  cans  or  other  receptacles  used  for  milk  or  cream  shall  be 
cleaned  thoroughly  upon  emptying. 

3.  The  cans  from  which  milk  or  cream  is  dipped  shall  be  packed  in 
ice,  and  shall  be  kept  covered  at  all  times,  except  when  the  milk  or 
cream  is  being  actually  dipped  therefrom. 

4.  After  each  day's  use  all  utensils  shall  be  thoroughly  cleaned  with 
hot  water  and  soda,  and  then  with  boiling  water. 

5.  All  utensils  used  for  dipped  milk  or  cream  shall  be  kept  clean. 

6.  The  ice  tubs  in  which  milk  or  cream  is  stored  shall  be  painted 
inside  and  outside,  and  shall  be  kept  clean  at  all  times. 

7.  A  separate  dipper  shall  be  provided  for  each  can  from  which  the 
supply  is  being  served,  and  such  dipper  shall  remain  in  the  can  between 
dippings  until  all  the  milk  in  the  can  has  been  disposed  of. 

8.  All  goods  sold  in  milk  stores  must  be  either  in  unbroken  packages, 
or  must  be  so  placed,  protected  and  handled  that  no  dust  or  odors 
therefrom  can  injuriously  affect  the  milk. 

9.  Dry  sweeping  and  dusting  in  rooms  in  which  milk  or  cream  is 
dispensed  is  prohibited. 

10.  The  tags  on  cans  of  milk  or  cream  must  be  kept  on  file  in  the  store 
for  at  least  two  months  for  inspection  by  the  Department  of  Health. 

11.  The  attendants  shall  wear  clean,  washable  outer  clothing. 

12.  Only  such  persons  shall  be  employed  as  are  free  from  infectious 
diseases  which  may  be  transmitted  in  the  handling  of  milk.^ 

A  permit  system  should  apply  to  stores,  which  should  be 
required  to  post  their  permits  in  a  conspicuous  place. 

The  Commission  on  Milk  Standards  prescribes  that  all 
stores  in  which  milk  is  handled  be  provided  with  a  suitable 
room  or  compartment  in  which  milk  shall  be  kept,  said  com- 
partment to  be  clean  and  so  arranged  that  the  milk  will  not 
be  liable  to  contamination. ^  The  maximum  temperature 
allowable  for  such  milk  is  set  by  the  Commission  as  50°  F. 

1  Weekly  Bull.  N.    Y.  City  Dept.  of  Health,  Aug.  30,  1913. 

2  Passaic,  N.  J.,  requires  that  each  store  have  a  special  milk  booth 
constructed  according  to  plans  furnished  by  the  health  department. 
Note,  howe\'er,  that  in  the  sixth  regulation  above,  ordinary-  booths  are 
disapproved. 


384  A  MANUAL   FOR   HEALTH   OFFICERS 

The  care  of  milk  in  the  home  is  a  subject  for  publicity. 
Some  health  departments  issue  circulars  urging  that  milk 
be  kept  clean,  cold  and  covered,  as  otherwise  a  good  deal 
of  the  benefit  of  inspection,  pasteurization  and  other  public 
precautions  is  lost.  Infant  hygiene  nurses  should  give 
instruction  on  this  point.     (See  page  313.) 

//.   LABORATORY  CONTROL 

Laboratory  examinations  of  milk  are  of  no  less  import- 
ance than  inspection;  in  fact  they  are  in  a  sense  even  more 
important,  for  by  them  alone  can  the  health  authorities 
learn  the  quality  of  the  milks  supplied  and  ascertain  where 
deficiencies  lie.  Without  laboratory  facilities  efforts  for 
improving  the  hygienic  character  of  milk  supplies  are  made 
in  the  dark.  Hence  every  department  of  health  should  be 
provided  with  a  laboratory  with  an  analyst  who  is  capable 
of  carrying  on  the  necessary  routine  bacteriological  exami- 
nations. Such  a  laboratory  is  not  expensive  to  equip  and 
maintain  (see  Appendix  D),  and  in  many  cases  the  milk 
inspector  with  laboratory  training  will  be  able  to  make  his 
own  examinations.  Small  communities  which  cannot 
afford  to  maintain  separate  laboratories  may  join  with 
others  in  the  maintenance  of  a  common  laboratory.  Money 
spent  for  laboratory  work  will  be  repaid  many  times  in 
benefit  to  the  public  health. 

Laboratory  work  may  be  mentioned  chiefly  under  the 
following  heads: 

1.  Collection  of  samples  (including  temperature  taking). 

2.  Bacteria  tests  (bacteria  counts). 

3.  Chemical  tests. 

4.  Tests  for  visible  dirt  (sediment). 

5.  Tests  for  adulteration  and  preservatives. 

In  addition,  if  facilities  allow,  examinations  may  be  made 
for  kinds  of  bacteria,  pus  cells,  etc. 

I.  Collection  of  Samples.  —  "  Samples  of  milk  should  be 
taken  at  regular  intervals  for  analysis.     These  should  be 


MILK    AND   OTIIKR    FOOT)    SUI'PLIIOS  385 

collected  largely  from  retail  delivery  waj^f;ns,  so  that  they 
will  represent  the  produet  received  by  consumers.  Where 
the  milk  is  bottled,  sampling  is  a  simple  matter,  as  one 
bottle  will  suffice  for  a  sample.  Where  milk  is  dipped  from 
cans  or  drawn  from  faucets,  sampling  is  not  so  easy.  How- 
ever, if  the  inspector  puts  himself  in  the  position  of  a  con- 
sumer, taking  the  product  sold  to  him  for  a  sample,  this  will 
represent  what  the  dealer  is  actually  selling.  .  .  .  Persons 
collecting  samples  should  be  familiar  with  the  manner  of 
taking  evidence  in  court  and  should  be  able  to  prove  the 
identity  of  the  sample  delivered  to  the  analyst.  It  should 
not  pass  out  of  sight  of  the  inspector  until  personally  de- 
livered to  the  man  in  the  laboratory  who  is  to  examine  it, 
unless  it  is  under  seal  and  properly  marked  for  identifica- 
tion. When  the  inspector  takes  several  samples  on  a 
single  trip,  each  sample  should  be  marked  as  soon  as  taken, 
so  that  no  question  can  be  successfully  raised  as  to  the 
possible  mixing  up  of  the  samples."  ^  State  laws  very 
frequently  prescribe  the  procedure  for  taking  legal  samples 
(providing,  for  example,  for  the  return  of  a  sealed  portion 
of  the  sample  to  the  dealer)  which  should  be  exactly 
followed  where  prosecution  is  planned.  In  such  cases  a 
witness  should  accompany  the  inspector.  For  ordinary 
collection  of  samples,  however,  ordinary  care  should  suf- 
fice, without  cumbersome  formality. 

For  the  collection  of  bacteriological  samples  of  loose  milk 
sterilized  four-ounce  bottles  with  wide  mouths  and  ground- 
in  stoppers  will  be  found  convenient;  care  should  be  taken 
to  protect  the  mouths  of  these,  before  and  after  filling,  by 
means  of  a  tin-foil  cap.  Milk  may  be  dipped  into  these  by 
the  dealer  just  as  it  would  be  given  to  an  ordinary  consumer. 
Other  methods  of  collection  are  given  in  the  text-books  on 
milk  examination.^ 

1  Lane  and  Whittaker,  Bureau  of  Animal  Industry,  Circular  139. 
'  Cf.  Tonney,  "  An  Inexpensive  Outfit  for  the  Collection  of  Bacterial 
Milk  Samples,"  Am.  Jour.  Pub.  Health,  1912,  vol.  II,  no.  5,  p.  364. 


386  A  MANUAL   FOR   HEALTH  OFFICERS 

Where  the  inspector  takes  the  sample  himself  he  should 
be  careful  to  mix  the  milk  thoroughly  and  to  the  satisfaction 
of  the  dealer,  so  as  to  get  a  representative  sample.  Pains 
must  be  taken  that  all  articles  used  in  the  collection  of  milk 
samples  be  thoroughly  sterilized  and  kept  so  until  use.  If 
temperature  is  taken,  an  accurate  and  clean  thermometer 
should  be  used  and  this  act  should  be  performed  after  the 
taking  of  the  bacteriological  sample. 

In  addition  to  the  samples  from  wagons,  collections  should 
be  made  of  store  milk,  which  will  usually  be  found  much  in 
need  of  bacteriological  control.  Samples  may  also  be  taken 
from  time  to  time  of  milk  before  bottling  and  in  transit,  if 
it  is  desired  to  locate  special  difficulties. 

Milk  samples  between  collection  and  examination  must, 
it  scarcely  needs  be  said,  be  kept  strictly  iced. 

Care  in  manipulation  must  be  exercised  throughout,  and 
the  collector  of  milk  samples  should  have  a  knowledge  of 
the  principles  of,  and  necessity  for,  bacteriological  cleanli- 
ness; otherwise  contaminations  which  would  vitiate  the 
final  results  may  occur. 

2.  Bacteria  Tests.  —  The  principal  bacteriological  test 
is  that  for  the  total  count,  expressed  as  "bacteria  per  cubic 
centimeter."  This  should  be  obtained  according  to  the 
standard  methods  of  the  Laboratory  Section  of  the  Ameri- 
can Public  Health  Association.^ 

The  importance  of  bacteria  counts,  especially  in  the 
grading  of  milks,  has  been  indicated  in  the  foregoing  pages. 
The  Commission  on  Milk  Standards  of  the  N.  Y.  Milk 
Committee  concludes  that  "among  present  available  routine 
laboratory  methods  for  determining  the  sanitary  quality 

^  For  reference  see  Appendix  D.  The  Commission  on  Milk  Stand- 
ards recommends  the  following  amendments:  "  A.  That  the  culture 
medium  used  for  testing  milk  be  identical  in  its  composition  and  re- 
action with  the  culture  medium  used  for  the  testing  of  water  provided 
in  the  standard  methods  of  water  analyses  of  the  American  Public 
Health  Association.  B.  That  incubation  of  plate  cultures  be  made  at 
37°  C.  for  48  hours."     (2d  Rpt.,  1913.) 


MILK  AND   OTHER    FOOD   SUPPLIES  387 

of  milk  the  bacteria  count  occupies  first  place."  In  the 
majority  of  instances  the  bacteria  indicate  dirt,  or  lac  k  of 
refrigeration,  or  age.  (The  total  count  has  no  direct  refer- 
ence to  the  specific  bacteria  (^f  disease,  see  below.)  In  the 
words  of  the  Commission,  "milk  with  a  high  bacteria  count 
is  not  necessarily  harmful,  but  when  used  as  a  food,  par- 
ticularly for  children,  is  a  hazard  too  great  to  be  warranted. 
Milk  with  a  high  bacteria  count,  therefore,  should  be  con- 
demned. Milks  with  small  numbers  of  bacteria  are  pre- 
sumed to  be  wholesome,  unless  there  is  reasonable  ground 
for  suspecting  that  they  have  been  exposed  to  contagion." 

Various  standards,  ranging  from  100,000  to  500,000 
bacteria  per  cubic  centimeter,  have  been  set  by  various 
communities  for  their  market  milk.  Those  recommended 
by  the  Commission  on  Milk  Standards  should  be  adopted 
as  representing  the  most  advanced  practice.  Naturally, 
however,  it  will  be  easier  for  communities  drawing  their 
supplies  from  nearby  to  obtain  low  bacteria  counts  than 
those  which  use  milk  brought  from  greater  distances  in 
longer  periods  of  time. 

There  is  a  diversity  of  opinion  as  to  the  best  method  of 
valuing  a  series  of  bacteria  counts.  The  average  of  the 
counts  for  a  certain  supply  would  indicate  the  average  num- 
ber of  bacteria  received  by  the  consumer  and  hence  the 
general  effect  on  health,  though  not  necessarily  showing 
individual  high  counts.  The  Commission  (191 3)  gives  the 
following  rule: 

That  the  grade  into  which  a  milk  falls  shall  be  determined  bacterio- 
logically  by  at  least  five  consecutive  bacteria  counts  taken  over  a  period 
of  not  less  than  one  week  nor  more  than  one  month,  and  at  least  80 
per  cent  (four  out  of  five)  must  fall  below  the  limit  set  for  the  grade  for 
which  the  classification  is  desired. 

A  similar  consideration  should  apply  to  the  publication 

of  laboratory  results,  so  that  the  tests  will  be  sufficiently 

numerous  to  be  truly  indicative;  single  scattered  tests  vary 

and  may  be  misleading  unless  a  sufficient  number  is  taken 

to  produce  a  reliable  average. 


388  A  MANUAL   FOR   HEALTH  OFFICERS 

In  laboratories  where  facilities  warrant,  additional  tests 
may  be  made  for  kinds  of  bacteria  (e.g.,  colon  and  other 
intestinal  types,  streptococci,  etc.).  It  is  a  rare  thing,  how- 
ever, for  a  laboratory  to  undertake  the  examination  of  milk 
for  the  detection  of  the  bacteria  of  disease,  because  of  the 
extreme  difficulties  in  detecting  them.  Nor,  in  many  cases, 
would  there  be  any  practical  advantage  even  if  such  tests 
were  successful,  for  the  fact  of  infection  can  be  established 
most  readily  by  epidemiological  evidence.  As  for  protec- 
tion from  such  infection,  the  most  effective  method  is  by 
medical,  veterinary  and  sanitary  inspection,  and  by  pas- 
teurization. 

3.  Chemical  Tests.  —  Chemical  tests  and  the  others 
which  will  be  mentioned  take  a  secondary  place  from  the 
sanitary  standpoint.  Chemical  tests  are,  however,  neces- 
sary as  an  indication  of  the  food  value  of  the  product  sold. 
Those  commonly  made  are  for  milk  fats  and  other  solids. 
The  Babcock  method  is  the  simplest  for  determining  the 
percentage  oi  fats.  If  at  the  same  time  lactometer  and  tem- 
perature readings  are  taken  the  total  solids  may  readily  be 
gauged  with  a  fair  degree  of  accuracy  by  means  of  the 
formulae  and  tables  given  in  the  laboratory  text-books. 
This  may  suffice  for  routine  procedure,  but  more  exact 
methods  (which,  however,  require  more  time)  — useful,  for 
example,  in  preparing  for  prosecution  —  are  described  in 
the  text-books  and  may  be  followed  where  laboratory 
facilities  permit.  The  chemical  results  may  be  expressed 
as  "fats"  and  "total  solids,"  or  as  "fats"  and  "solids  not 
fat."  The  standards  adopted  for  whole  milk  should  be 
those  of  the  Commission  on  Milk  Standards:  3.25  per  cent 
fat  and  8.5  per  cent  solids  not  fat. 

In  the  interpretation  of  percentages  it  should  be  borne  in 
mind  that  falling  below  the  standard  does  not  necessarily 
indicate  fraud  through  skimming  or  added  water,  but  may 
be  due  to  the  use  of  cattle  giving  a  thin  milk.  This  is 
especially  true  of  certain  breeds.     This  does  not,  however, 


MILK   AND   OTHER    FOOD   SUPPLIES  389 

constitute  an  excuse  for  the  dairyman,  wIk;  should  obtain 
his  supply  from  herds  so  composed  that  they  give  the 
recjuired  food  values.  Adulteration  of  milk  through  water- 
ing and  skimming  will  be  mentioned  below. 

4.  Tests  for  Visible  Dirt  (Sediment).  —  These  have 
come  into  considerable  use,  principally  because  they  dem- 
onstrate visibly  the  gross  forms  of  dirt  in  milk  in  a  manner 
which  is  convincing  to  the  dairyman  and  the  public.  Thus 
they  are  supplementary  to  the  bacteria  tests,  which  of 
course  gauge  to  a  far  finer  degree  the  effects  of  dirt.  Dirt 
in  milk  may  be  detected  by  examining  the  bottom  of  the 
bottle  after  the  sample  has  stood  for  an  hour.  It  is  deter- 
mined quantitatively  by  methods  involving  centrifugalizing 
or  straining,  which  are  described  in  recent  text-books  and 
papers.  A  recent  paper  mentions  a  dozen  or  more  such 
methods.^  Several  dirt  testers  are  now  ofifered  on  the  mar- 
ket. A  quart  or  pint  of  the  milk  is  usually  strained  through 
a  cotton  disk,  the  visible  dirt  being  retained  upon  the  latter; 
the  disk  is  then  dried  and  may  be  cut  in  two,  one-half  being 
given  to  the  dealer  and  the  other  kept  on  file.  A  series  of 
grades  according  to  the  amount  of  sediment  may  be  estab- 
lished. The  sediment  consists  of  undissolved  cow  manure, 
dust,  hairs  and  other  foreign  matter,  which  fact,  stated  to 
the  dairyman,  assists  in  the  improvement  of  dairy  methods, 
especially  if  the  tests  are  made  a  matter  for  public  exhibi- 
tion. It  should  be  especially  impressed  that  this  dirt 
should  be  kept  out  originally  rather  than  be  strained  out 
after  contamination  has  taken  place.  Comparative  tests 
are  made  of  the  supplies  of  their  individual  producers  by 
various  large  creameries,  as  well  as  by  health  authorities, 
and  the  results  posted,  with  good  results.  It  must  be  borne 
in  mind,  however,  that  while  this  is  a  useful,  it  is  strictly  a 
subsidiary,  method  of  laboratory  control. 

^  Schroeder,  "  Dirt  Sediment  Testing  —  A  Factor  in  Obtaining  Clean 
Milk,"  Am.  Jour.  Pub.  Health,  1914,  vol.  IV,  no.  i,  p.  50.  Cf.  Tonney, 
ibid.,  1912,  vol.  II,  no,  4,  p.  280,  and  Schroeder,  ibid.,  1912,  vol.  II, 
no.  5,  p.  360. 


390  A  MANUAL'  FOR  HEALTH  OFFICERS 

5.  Tests  for  Adulteration  and  Preservatives.  —  Where 
tests  of  this  class  have  been  regularly  carried  on  it  is  found 
that  the  addition  of  adulterant  or  preservative  seldom 
occurs.  Such  tests  arc  readily  performed,  and  the  heavy 
penalties  which  in  the  past  have  been  applied  have  resulted 
in  effectually  discouraging  the  tendencies  to  this  class  of 
frauds.  The  adulteration  of  milk  through  watering  or 
skimming  still,  however,  occurs  not  infrequently,  especially 
wiiere  few  or  no  tests  are  made  by  the  health  authorities. 

Where  milk  is  adulterated  through  watering  or  skimming 
the  penalty  should  be  more  severe  than  where  it  is  simply 
below  the  standard  for  solids.  In  order,  however,  to  prove 
such  adulteration  it  is  necessary  to  resort  to  refractometer 
tests,  and  recourse  should  therefore  be  had  to  a  laboratory 
where  such  can  be  made.  Examinations  of  this  class,  in 
cases  where  prosecution  is  to  be  imdertaken,  require  strict 
legal  procedure  and  adequate  laboratory  technique.  Hence 
they  are  best  usually  assigned  to  state  food  and  drug  in- 
spection service. 

Among  possible  preservatives  of  milk  and  cream  formalin 
is  the  chief. 

The  addition  of  formalin,  as  well  as  most  other  forms  of 
adulteration  and  preservation,  can  readily  be  detected  by 
simple  tests.  When  preservative  is  used  it  may  frequently 
be  suspected  from  the  abnormally  low  bacteria  count  which 
results. 

Cream  is  subject  to  addition  of  thickeners  (e.g.,  gelatin) 
and  preservatives,  for  which  tests  may  be  made  in  suspected 
cases. 

In  general,  it  seems  necessary  for  local  authorities  to  make 
tests  for  adulteration  and  addition  of  preservative,  not  as  a 
routine  measure,  but  only  in  those  cases  rendered  suspect  by 
the  results  of  the  regular  bacteriological  and  chemical  tests. 

For  methods  see  text-book  references  at  close  of  this 
section.  (Cf.  Bull.  100,  U.  S.  Bureau  of  Chemistry,  on 
simple  tests.) 


MILK    AND   O'I'III'IK    I'f)f)l)    SlJI'I'lJIlS  391 

The  subject  of  microscopic  examination  of  milk  and  the 
detcniiimition  of  pus  and  bacteria  by  sedimentation 
methods  is  one  in  which  general  agreement  as  to  values  and 
methods  has  not  been  reached.  It  is  now  under  considera- 
tion by  a  siK'cial  sulocomniittee  of  the  Commission  on  Milk 
Standards  aiid  will  be  reported  upon  later. 

Frequency  of  Tests. — ^  As  a  gener^il  rule,  every  su[)ply 
should  be  subjected  to  bacteriological  and  chemical  exami- 
nation at  least  once  a  month.  Low-grade  and  suspected 
supplies  should  be  examined  more  frequently,  and  a  policy 
of  following  up  such  supplies  will  produce  much  better 
results  than  an  undiscriminating  routine.  During  warm 
weather  the  frequency  of  examination  should  be  increased. 
If  laboratory  facilities  arc  limited,  special  attention  should 
be  paid  to  making  frequent  bacteriological  tests,  even  if  the 
number  of  chemical  tests  does  not  keep  pace;  for  the  former 
are  of  greater  significance  to  the  public  health. 

MILK  PRODUCTS 

After  milk,  attention  should  be  paid  to  cream  and  ice 
cream  supplies.  The  standards  adopted  for  cream  should 
be  those  of  the  Commission  on  Milk  Standards,  which 
provide  that  "cream  should  be  classified  in  the  same 
grades  as  milk,  in  accordance  with  the  requirements  for 
the  grades  of  milk,  excepting  the  bacterial  standards  which 
in  20  per  cent  cream  shall  not  exceed  five  times  the  bac- 
terial standard  allowed  in  the  grade  of  milk"  (modification 
of  bacterial  standard  according  to  percentage  of  fat  when 
this  percentage  is  different  from  20) ,  while  standard  cream 
is  to  contain  "not  less  than  18  per  cent  of  milk  fat"  and 
to  be  "free  from  all  constituents  foreign  to  normal  milk." 

The  regulation  of  ice  cream,  requires  some  special  remark. 
Ice  cream  is  frequently  made  from  poor  grades  of  milk  and 
cream  and  under  the  most  unsanitary  conditions,  often 
in  dark,  dirty  basements.  Yet  the  product  is  consumed 
to  a  large  extent  by  children  and  invalids,  the  most  sus- 


392  A   MANUAL    I'OR    lII-Al/ni   omCERS 

ccptible  part  of  the  population.  Hence  it  requires  careful 
sanitary  regulation,  consisting  both  in  inspection  (for  which 
a  score-card  similar  to  that  for  milk  plants  may  be  used) 
and  analyses  of  the  raw  materials  and  of  the  finished 
product.  In  the  inspection  special  attention  should  be 
paid  to  the  care  of  utensils,  the  prevalence  of  fllies  and  the 
ol\iectional)le  use  of  the  fingers  in  tasting  and  handling  the 
product;  for  the  latter  purposes  proper  spoons  and  other 
utensils  are  to  be  insisted  upon.  In  New  Jersey  a  special 
score-card  has  been  adopted  and  inspections  are  made  by 
the  State  Department  of  Health,  the  estai)lishments  being 
required  to  come  up  to  certain  requirements  before  a  license 
is  issued.  This  gives  the  advantage  of  uniform  and  expert 
inspections,  but  elsewhere  it  may  be  necessary  for  many 
communities  to  look  after  their  own  inspections. 

In  Montclair,  N.  J.,  where  a  special  effort  has  been  made 
to  improve  the  ice  cream  supplies  a  bacterial  limit  of 
"500,000  bacteria  per  cubic  centimeter,  measurement  to  be 
made  immediately  after  the  ice  cream  has  been  reduced  to 
a  Ikiid  condition,"  has  been  adopted.  The  pasteurization 
of  milk  and  cream  used  in  making  ice  cream  may  be  per- 
mitted under  proper  conditions. 

The  percentage  of  fat  in  ice  cream,  though  secondary  to 
cleanly  conditions  of  manufacture  and  the  purity  of  the 
product,  is  important  as  indicating  the  food  value.  Anal- 
yses made  in  Montclair  showed  that  this  figure  ranged 
from  3.0  to  17.0  per  cent.  Standards  should  be  established 
or  at  least  the  results  should  be  published  and  the  dealers 
required  to  guarantee  a  certain  percentage  by  statement  on 
the  label,  especially  as  gelatin  thickener  is  frequently  used. 

Health  departments  should  publish  data  and  remarks 
under  all  of  the  above  heads,  relative  to  the  local  ice  cream 
supplies.^ 

'  See  Rpt.  of  Bd.  of  Health  of  Montclair,  N.  J.,  for  1913;  and  Bahl- 
man,  "  Ice  Cream  Studies  in  Cincinnati,"  Am.  Jour.  Pub.  Health,  1914, 
vol.  IV,  no.  II,  p.  1009. 


MILK   ANT)   OTirrOR    I'T)f)I)    SUF'I'I.IKS  393 

Other  milk  products  subject  to  supcrvisifm  are  skim  milk 
and  IjLittermilk  (see  R|)t.  of  Commission  on  Milk  Slaiul- 
ards),  butter,  condensed  milk,  etc.  Since  Ijutter  is  a  p(;Len- 
tial  vehicle  of  l^ovinc  tuberculosis,  it  should  be  made  from 
tuberculin-tested  or  pasteurized  supplies  (A  milk  or  cream. 
Strict  conditions  of  cleanliness  should  be  observed  in  places 
where  milk  products  are  produced  and  handled,  and  s(j  far 
as  practicable  pasteurization  of  the  raw  materials  or  fm- 
ished  product  should  be  practiced. 

ENFORCEMENT  OF  STANDARDS 

Legal  Remedies.  —  The  following  legal  remedies  are 
available: 

1.  Fines.  —  In  connection  with  bacteria  counts  two  or 
more  consecutive  excessive  counts  should  be  obtained  as  a 
basis  for  prosecution.  With  substandard  chemical  tests 
it  is  customary  to  issue  a  warning  on  the  first  tests,  prose- 
cution being  undertaken  if  the  supply  continues  below 
standard.  The  law  should  provide  increasing  penalties  for 
subsequent  offences.  If  fraudulent  adulteration,  etc.,  is 
proved,  prosecution  is  at  once  demanded. 

2.  Revocation  of  Permit.  — Where  this  is  provided  for  in 
the  law  it  affords  a  powerful  check,  which  can,  however, 
only  be  applied  where  conditions  are  continuously  bad. 

3.  Arbitrary  Confiscation,  destruction  or  denaturization 
of  milk  is  a  comparatively  rare  procedure,  too  drastic  for 
most  cases.  It  could  only  be  applied  when  the  product 
contains  visible  dirt  or  has  a  very  low  specific  gravity  or  is 
above  temperature  standard  —  in  other  words  when  the 
violation  of  standards  is  demonstrable  on  the  spot. 

Publicity  of  conditions  and  laboratory  results  (see  below) 
is  a  valuable  auxiliary  means  in  the  enforcement  of  milk 
standards. 

The  Economic  Problem.  —  The  improvement  of  milk 
supplies  is  at  bottom  an  economic  problem.  Improve- 
ments require  expenditure  of  money  or  of  labor,  and  justice 


394  A  MANUAL   FOR   HEALTH  OFFICERS 

requires  and  practice  shows  that  an  increased  price  must  be 
paid  by  the  consumer.  Tlie  u,Ta(Hng  of  market  milks  clears 
the  situation  greatly  by  enabling  the  better  grades  to  be 
sold  at  the  somewhat  increased  price  that  they  merit.  At 
the  same  time  it  may  result  in  decreasing  the  prices  now 
obtained  for  inferior  grades.  On  the  whole,  however,  im- 
proved sanitation  means  corresponding,  though  not  neces- 
sarily great,  increases  in  prices.  Hence,  while  the  health 
officer  is  setting  and  endeavoring  to  enforce  higher  standards 
he  must  also  stimulate  a  public  demand  and  willingness  to 
pay  for  the  better  product;  and  this  requires  public  en- 
lightenment. 

The  success  achieved  by  the  experiment  in  milk  pro- 
duction which  has  been  carried  out  on  a  large  scale  by  the 
New  York  Dairy  Demonstration  Company  is  an  illustra- 
tion of  the  fact  that  an  extra  price  or  premium  paid  to  the 
producer  for  cleanliness  and  care  will  bring  results  far  more 
quickly  and  certainly  than  instructions  or  official  inspection. 
In  this  successful  experiment  the  following  premiums  were 
paid  to  the  farmers: 

For  tuberculin-tested  cows l^  per  quart 

For  "  sanitation"  (milking  in  covered  pails  washed  and 

sterilized  at  the  receiving  station,  and  cooling  with  ice)  i  ^ 

For  keeping  bacteria  count  under  10,000  per  c.c \_i 

Total i^ 

The  additional  cost  of  running  the  sterilizing  station,  over 
and  above  that  of  an  ordinary  bottling  station,  was  |j*, 
thereby  making  the  additional  cost  necessary  to  supply  a 
tuberculin-tested  milk  with  a  bacteria  count  under  30,000 
at  time  of  delivery,  one  and  one-half  cents  per  quart. ^ 
Similar  additional  costs  might  be  worked  out  for  pasteuri- 
zation and  other  factors. 

In  future  milk  should  be  sold  on  sanitary  grade  and  food 
value,  the  choice  of  quality  resting  with  the  consumer  who 

•  North,  "  Sterilizing  Stations  in  Dairy  Districts,"  A^n.  Jour.  Pub. 
Health,  191 1,  vol.  I,  no.  9,  p.  654. 


MII.K    AND    O'I'IIICK    lOOh    SlJI'I'lJIlS  395 

should  have  full  knowledge  of  what  he  is  getting  and  be 
willing  to  pay  the  corresponding  price. 

Publicity.  —  We  have  eilready  alluded  tf;  the  advantages 
of  publicity  in  the  improvement  of  milk  supplies.  The 
most  effective  form  that  this  can  take  is  the  publication  of 
the  results  of  laboratory  analyses,  preferably  in  the  form 
of  quarterly  or  semi-annual  bulletins  which  may  be  distrib- 
uted from  house  to  house.  This  method  is  particularly 
applicable  to  small  communities.  It  enables  the  consumer 
to  choose  a  supply  more  accurately  than  is  afforded  by  the 
market  grading  system.  In  Montclair,  N.  J.,  much  benefit 
has  resulted  in  the  publication  of  such  results  in  the  annual 
reports  of  the  health  department,  a  partial  reprint  of  which 
is  distributed  from  house  to  house.  We  assume  of  course 
that  proper  regulations  have  been  established,  that  there 
are  adequate  laboratory  facilities  and  that  sufficiently 
numerous  tests  are  made. 

Circulars  on  the  care  of  milk  in  the  home  may  also  with 
advantage  be  distributed. 

Exhibitions,  especially  at  the  outset  of  a  milk  campaign, 
are  useful.^ 

ORGANIZATION 

The  ideal  organization  for  the  administration  of  milk 
laws  would  involve  a  combination  of  state  and  local  inspec- 
tion and  laboratory  work.  Under  such  a  plan  milk  and 
milk  products  from  the  time  of  their  origin  at  the  dair}^ 
farm,  in  transportation,  country  bottling,  etc.,  would  be 
under  the  supervision  of  the  state  authorities  (state  health 
authorities  in  cooperation  with  state  agricultural  authori- 
ties) ;  upon  their  entrance  within  the  limits  of  the  local 
municipality  they  would  come  under  the  supervision  of  the 
local  authorities.  The  supervision  in  both  cases  would 
include  both  inspection  and  laboratory  work.     The  local 

^  For  suggestions  see  the  Report  of  the  Philadelphia  Milk  Show, 
191 1  (Phila.  Bureau  of  Municipal  Research). 


396  A  MANUAL   FOR   HEALTH  OFFICERS 

municipality  could  enforce  its  own  ordinances  through 
cooperation  with  the  state  authorities,  such  cooperation 
taking  the  form  of  furnishing  reports  and  evidence.  The 
state  inspection  of  dairies  is  ()l)\i()usl\'  an  advantage  for 
the  reason  that  overlapping  in  the  same  district  of  the  in- 
spections of  several  different  municipalities  is  avoided,  that 
a  dairy  condemned  by  one  community  cannot  divert  its 
product  into  another  without  detection  and  that  more 
uniformity  of  methods  may  be  secured.  But  whatever  the 
relationships  may  be,  the  principal  authoriu-  must  naturally 
reside  in  the  local  health  department,  and  when,  as  fre- 
quentl>-  is  the  case,  the  appropriations  to  state  departments 
for  milk  supervision  are  insufficient  to  carry  into  complete 
effect  the  plan  which  has  just  been  proposed,  local  depart- 
ments must  rely  very  largely,  perhaps  wholly,  on  their  own 
resources. 

The  number  of  inspectors  necessary  will  vary  according 
to  the  number  and  distribution  of  the  dairies  and  other 
establishments  to  be  visited.  One  authority  states  that 
there  should,  as  a  rule,  be  one  inspector  for,  approximately, 
every  lOO  dairies  ^  for  the  country  inspections;  in  addition 
there  would  be  the  inspection  of  receiving  and  bottling 
stations,  and  the  collection  of  samples,  which  might  perhaps 
be  handled  by  the  same  man. 

Besides  the  inspection  service  there  must  be  local  labora- 
tory facilities  and  services.  It  is  impossible  to  lay  down 
exact  standards  as  to  practical  requirements;  the  needs 
of  each   community   must    be    considered.     A   number  of 

1  Some  of  the  questions  relating  to  number  of  inspectors,  of  samples 
to  be  taken  and  the  like  have  been  considered  by  Gunn  in  a  report  on 
the  milk  control  situation  in  Milwaukee  (see  reference  at  close  of  this 
section).  He  states  that  relatively  the  greatest  amount  of  inspection  is 
performed  in  Richmond,  Va.,  where  there  are  only  66  farms  per  dairy 
inspector.  The  Philadelphia  Milk  Commission  recommended  approxi- 
mately 150  farms  per  country  inspector  (12  visits  per  year  to  each  farm, 
on  the  average,  some  more  and  some  less  according  to  conditions  at 
each). 


MILK   ANF)   OTIlKF<    I'ODI)    SUF'FMJKS  397 

cities  require  a  milk  analyst  and  one  or  more  milk  in- 
spectors. In  smaller  communities,  one  inspector  trained 
in  both  dairy  inspection  and  laboratory  work  may  be  able 
to  perform  all  the  inspection  and  laboratory  work  rcfiuircd. 
Still  smaller  places  may  cooperate  with  neighborint^  j)la(  es 
in  the  maintenance  of  a  joint  inspection  and  labfjratory 
arrangement.  Thus  no  community,  however  small,  should 
be  without  adequate  expert  service. 

In  every  case  milk  work  should  be  a  distinct  branch  of 
health  department  activity,  requiring  for  its  execution,  men 
specially  qualified  by  training  and  experience.  Halfway 
measures  and  ill-advised  methods  lead  invariably  to  failure 
if  not  to  harm. 

A  special  effort  should  be  made  to  obtain  the  good-will 
of  dairymen  and  dealers  through  tactful  and  instructive 
methods,  to  educate  public  opinion  to  higher  standards 
and  to  use  methods  and  statements  which  safeguard  and 
improve  and,  without  arousing  needless  apprehension, 
further  public  convenience  and  confidence. 

REFERENCES 

Reports  of  the  Commission  on  Milk  Standards  appointed  by  the  New 
York  Milk  Committee,  N.  Y.  Milk  Com.,  105  East  22nd  St.,  N.  Y.  City. 

Savage,  "  Milk  and  the  Public  Health  "  (bacteriology  and  adminis- 
trative control),  London,  1912. 

Jensen,  "  Milk  Hygiene  "  (translated  by  Pearson). 

Winslow  (Kenelm),  "  The  Production  and  Handling  of  Clean  Milk, 
Including  Practical  Milk  Inspection  "  (with  "  The  Essentials  of  Milk 
Bacteriology,"  by  H.  P.  Hill). 

Ward,  "  Pure  Milk  and  the  Public  Health." 

Rosenau,"The  Milk  Question,"  1912  (popular  in  style). 

Magruder,  "  The  Solution  of  the  Milk  Problem,"  R.  Beresford, 
605  F.  St.,  N.W.,  Washington,  D.C.,  1913  (pamphlet,  10  cts.). 

Trans.  XV.  Internal.  Congress  on  Hyg.  and  Demogr.,  191 2,  Govt. 
Printing  Office,  Washington  (vol.  IV). 

A  mass  of  useful  information  is  contained  in  the  U.  S.  Government 
publications,  a  list  of  which  may  be  obtained  from  the  Supt.  of  Docu- 
ments, Government  Printing  Office,  Washington,  and  in  the  publica- 
tions of  state  agricultural  experiment  stations.     These  are  partly  the 


398  A  MANUAL   FOR   HI-ALTH  OFFICERS 

results  of  oflicial  invcsligatioiis  and  study,  and  partly  in  the  nature  of 
material  for  instruction  of  farmers  and  public.  The  sanitarian  and 
health  officer  should  consult  especially  Bull.  56  of  the  Hygienic  Labora- 
tory, Public  Health  Service,  on  "  Milk  in  Its  Relation  to  the  Public 
Health." 

As  an  example  of  a  milk  supply  survey  see  "  Report  of  a  Special 
Committee  apiwinted  by  the  Washington  Chamber  of  Commerce  to 
investigate  the  Milk  Situation  in  the  District  of  Columbia,"  191 1, 
Senate  Document  No.  863,  6ist  Congress,  3d  session;  Gunn,  "  The 
Milk  Sujiply  of  the  City  of  Milwaukee  and  Its  Control  by  the  Health 
Department,"  Milwaukee  Bur.  of  Efficiency  and  Economy,  Bull.  No.  13, 
1912. 

For  laboratory  references  sec  Appendi.\  D. 

For  references  on  transmission  of  disease  by  milk  see  Epidemiology, 
Chapter  I. 

II.   FOODS   OTHER   THAN   MILK 

Regulation  of  food  supplies  in  general  is  directed  against 
the  following  classes  of  conditions: 

1.  Infection.  —  Preventive  measures  should  forbid  the 
possibility  of  contamination  of  foods  at  any  stage  with 
infectious  matter,  and,  in  the  case  of  meats,  the  sale  of 
dangerously  diseased  portions.  The  requirements  of  this 
class  apply  especially  to  foods  eaten  raw. 

2.  Contamination  with  Dirt  and  Other  Foreign  Matter.  — 
Measures  under  this  head  may  be  referred  to  as  "general 
sanitation"  and  are  closely  connected  with  those  just 
mentioned. 

3.  Decomposition.  —  While  it  is  obviously  important 
that  no  decomposed  foods  be  sold,  this  department  of  food 
inspection  has  been  exaggerated  as  applied  to  foods  which 
are  obviously  unfit  for  consumption.  More  attention 
might  well  be  paid,  however,  to  the  character  of  raw 
materials  used  in  restaurants  and  the  like.  The  effects  of 
cold  storage  on  food  supplies  have  come  in  for  a  good  deal 
of  attention  of  late.^ 

'  Rpts.  of  Committee  on  Cold  Storage  of  the  Am.  Pub.  Health 
Assn.,  published  in  Arn.  Jour.  Pub.  Health. 


MILK   AND   OTIIKR    FOOT)    SUTM'IJF';S  399 

4.  Adulteration,  Preservatives,  etc. — This  head  iiuliidcs 
substitutions,  a(hnixturcs  and  sul:)tracti(jns  which  arf(;c;t 
the  quality  or  strength  of  articles;  also  the  use  of  dele- 
terious preservatives,  and  the  use  of  coloring  or  preserva- 
tive or  other  substance  to  conceal  inferiority.  We  may 
include  here  also  poisonous  inorganic  substances  which  may 
gain  access  to  foods  in  the  process  of  manufacture,  canning, 
etc.  Lead  poisoning  from  beverages  would  likewise  fall 
under  this  head.  As  to  harmful  and  harmless  preservatives 
the  line  is  often  difficult  to  draw  and  the  term  "poison"  as 
applied  in  this  connection  difficult  to  define.  For  the  whole 
question  of  harmful  substances  in  foods  and  beverages  the 
larger  text-books  (especially  that  by  Wiley)  should  be 
consulted. 

Many  if  not  most  of  the  violations  under  this  head  ob- 
viously bear  upon  honesty,  the  consumer's  purse,  etc.,  as 
well  as  health.  The  laws  covering  adulteration  and  mis- 
branding of  foods  and  drugs  are  chiefly  administered  by 
state  and  federal  authorities. 

On  the  whole,  the  main  public  health  aspects  of  food 
supplies  other  than  milk  relate  to  those  foods  which  may 
be  infected  and  convey  infection  through  being  consumed 
in  the  raw  state.  Otherwdse  (leaving  out  of  our  present 
scope  dietetic  and  nutritional  problems)  the  matters  here 
considered  raise  comparatively  few  responsibilities  for  the 
local  health  officer. 

Meat  Supplies.  —  Meats  and  meat  products  are  objec- 
tionable if  they  are,  in  whole  or  in  part,  filthy  or  decom- 
posed, or  if  they  embrace  any  portion  of  an  animal  unfit 
for  food,  or  if  they  are  the  product  of  diseased  animals  or 
those  that  have  died  otherwise  than  by  slaughter.  Such 
conditions  are  to  be  obviated  through  inspections  of 
slaughterhouses,  veterinary  inspection  of  animals  before 
slaughter  and  of  the  carcasses  after  slaughter,  and  super- 
vision  of   handling.     Such    inspections   are    properly    the 


400  A  MANUAL  FOR  HEALTH  OFFICERS 

function  of  State  and  Federal  authorities,  though  they  should 
be  performed  by  the  local  authorities  where  the  former 
are  inadequate.  State  systems  of  inspecting  and  licensing 
slaughterhouses  and  slaughtering  are  very  desirable. 

The  fact  that  meat  is  practically  always  cooked  before 
consumption  is  a  vast  safeguard  against  infection,  but 
since  cooking  may  be  incomplete,  the  consumer  should  be 
protected  by  an  inspection  that  ensures  him  products  as 
nearly  free  from  infection  as  possible.  Seriously  diseased 
meat  is  of  course  an  unfit  food  under  any  circumstances, 
though  when  a  diseased  animal  is  affected  only  locally, 
only  the  parts  affected  need  be  condemned.  Among  the 
diseases  which  may  be  communicated  from  animals  to  man 
through  uncooked  meat  may  be  mentioned  tuberculosis, 
trichinosis,  tape-worm  and  actinomycosis. 

A  great  deal  of  meat  is  inspected  by  the  Federal  Bureau 
of  Animal  Industry,  but  it  must  be  remembered  that  such 
inspection  covers  only  products  intended  for  interstate  or 
foreign  commerce,  so  that  consequently  large  quantities 
of  meat  killed  and  consumed  within  state  borders  is,  in  the 
absence  of  state  supervision,  not  subject  to  any  inspection.^ 

MEAT  INFECTION  AND  POISONING,  "PTOMAINES,"  ETC. 
Meat  may  become  infected  with  bacteria  of  the  paratyphoid  or  the 
hog  cholera  group,  the  infection  being  derived  either  from  disease  in  the 
animal  before  slaughter  or  from  postmortem  contamination  from  soiled 
hands,  butcher's  tools  or  fixtures,  cloths,  dust,  or  other  objects  with 
which  it  comes  in  contact,  or  from  flies.     In  this  way  there  is  an  anal- 

'  The  following  ordinance  has  been  adopted  in  Montclair,  N.  J.: 
"  No  pork,  beef,  veal,  mutton  or  lamb  nor  any  part  of  any  animal  from 
which  any  of  said  meats  is  obtained  shall  be  sold  for  food  purposes  or 
exposed  for  sale  or  held  in  possession  in  a  store  in  which  food  is  sold, 
unless  the  said  animal  has  been  examined  both  before  and  after  slaughter 
by  a  meat  inspector  duly  appointed  by  the  United  States  Government, 
or  by  some  other  competent  public  official,  and  has  been  passed  as  fit 
for  food  and  has  been  stamped  with  a  proper  identification  mark  or 
marks  according  to  the  system  adopted  by  the  United  States  Bureau 
of  Animal  Industry.  The  provisions  of  this  ordinance  shall  be  con- 
strued to  apply  to  all  meat  sausages  and  chopped  meats." 


MILK   ANF)   OTHKR    I'OOh   SUPPLIES  401 

ogy  to  milk  infection.  The  bacteria  have  their  usual  habitat  in  man 
(paratyphoid  bacillus)  or  lower  anilnals  (hog  cholera  bacillus,  etc.), 
but  when  they  gain  access  to  meat  and  conditions  as  to  warmth,  etc., 
are  favorable,  they  multiply  readily.  "  Cases  of  meat  poisoning  vary 
greatly  in  intensity  and  also  in  their  clinical  picture.  The  period  of 
incubation  in  the  acute  gastroenteric  type  is  usually  short,  rarely  over 
48  hours;  the  period  of  incubation  in  the  cases  resembling  typhoifl  fever 
is  generally  from  8  to  18  days."  ' 

Meat  inspection  affords  comparatively  little  protection  against 
bacterial  infections  of  this  class  for  the  reason  that  the  bacteria  may 
grow  extensively  without  altering  the  perceptible  qualities  of  the  meat. 
Their  presence  may  be  detected  only  by  bacteriological  examination. 
Of  course  it  goes  without  saying  that  animals  having  diseased  conditions 
capable  of  producing  meat  infection  should  be  condemned.  Since 
infection  of  meat  may  take  place  any  time  between  slaughter  and  con- 
sumption, scrupulous  cleanliness  should  be  observed  in  slaughter 
houses,  butcher  shops  and  the  home.  "  The  butcher's  hands  and 
implements,"  recommends  Rosenau,  "  require  cleanliness  of  a  surgical 
order."  Chopping  and  mincing  favor  infection  of  the  mass  of  meat. 
Thorough  cooking  destroys  the  infection,  hence  cases  of  meat  poisoning 
are  rare  among  those  whose  food  is  properly  cooked.  Meat  may,  how- 
ever, become  infected  after  cooking  if  not  properly  cared  for. 

Botulismus  is  another  type  of  meat  poisoning,  a  true  intoxication 
due  to  the  production,  by  a  specific  saprophytic  organism  {Bacillus 
hotulinus),  of  a  bacterial  toxine.  Meat,  fish  and  even  vegetables  con- 
taining sufficient  protein  are  subject  to  infection  by  this  organism  — 
most  frequently  sausages,  hence  the  name  "  sausage  poisoning."  The 
organism  is  a  strict  anaerobe,  i.e.,  grows  only  in  the  absence  of  air  and 
oxygen.  It  is  in  itself  harmless  and  does  not  grow  within  the  body; 
the  poisoning  is  caused  solely  by  the  toxine  generated  in  the  meat  before 
ingestion.  Sometimes  the  presence  of  toxine  can  be  detected  by 
changes  in  color,  taste,  odor,  etc.,  of  the  article;  sometimes  not.  The 
period  of  "  incubation  "  of  the  poisoning  before  symptoms  appear  is 
about  20  to  24  hours.  Most  of  the  cases  of  botulismus  are  reported 
from  Europe.  Prevention  is  a  matter  of  care  and  cleanliness  in  the 
handling  and  preservation  of  nitrogenous  foods.  There  is  no  danger 
in  fresh  or  properly  preserved  foods.  The  chief  danger  is  from  sausages 
eaten  without  sufficient  cooking.  Thorough  cooking  destroys  the  toxine. 
The  bacillus  is  capable  of  growing  well,  however,  in  cooked  foods.  A 
specific  preventive  antitoxin  may  be  prepared  by  the  usual  methods. 

1  Rosenau,  "  Preventive  Medicine  and  Hygiene,"  1913,  in  which 
a  fuller  description  of  symptoms,  etiology,  etc.,  of  diseases  mentioned 
in  this  section  is  given. 


402  A   MANUAL    FOR   IIKALTII   OFFICERS 

Uncooked  or  insufficiently  cooked  meat  may  also  transmit  to  man 
tuberculosis,  tapeworm  (from  beef,  pork  or  fish),  trichinosis  (from  the 
hog),  actinomycosis  and  other  diseases  of  the  lower  animals,  such  as 
those  we  have  mentioned  in  Chapter  I. 

"  Bob  veal  "  (from  calves  less  than  two  or  three  weeks  old),  the  sale 
of  which  has  frequently  been  forbidden  by  health  authorities,  is  objec- 
tionable on  humanitarian  and  esthetic  grounds,  and  is  more  subject  to 
infection  from  the  living  animal  and  to  bacterial  growth  and  decompo- 
sition after  slaughter  than  mature  meat. 

"  Ptomaine  poisoning  "  is  a  name  given  in  common,  and  frequently 
in  medical,  parlance  to  any  sickness  supposed  to  be  due  to  the  eating 
of  decomposed  food.  Chemically,  the  ptomaines  are  products  of  the 
putrefaction  of  proteins;  they  may  or  may  not  be  poisonous.  Some  of 
them,  at  least,  are  not  destroyed  by  the  heat  of  cooking.  This  class 
of  poisonings  is  obscure  owing  to  the  fact  that  few  instances  have 
been  studied  thoroughly,  clinically,  bactcriologically  and  chemically. 
Rosenau  states  that  "  the  more  the  question  of  ptomaines  is  studied  the 
less  do  they  appear  concerned  in  cases  of  food  poisons.  It  is  now  clear 
that  most,  if  not  all,  cases  of  so-called  ptomaine  poisoning  are  nothing 
more  nor  less  than  acute  infections  with  B.  paratyphosus,  B.  enteriditis, 
B.  cholerac  suis  and  other  microorganisms  belonging  to  this  group  " 
(see  remarks  on  meat  poisoning,  above).  Pellagra,  a  disease  thought 
by  some  observers  to  be  connected  with  spoiled  corn,  has  already  been 
discussed  in  Chapter  I. 

Establishments  where  Food  is  Prepared,  Handled  or 
Sold.  —  111  a  preceding  section  we  have  made  some  remarks 
relative  to  the  supervision  of  ice-cream  factories.  Similar 
regulation  should  apply  to  bakeries  and  confectioneries,  in 
which  uncleanlincss  of  equipment  and  methods  and  oppor- 
tunities for  infection  of  products  by  employees  are  fre- 
quently to  be  found.  Since  it  is  not  practically  possible 
to  insure  that  the  employees  in  such  establishments  are  not 
carriers  of  disease,  inspection  is  here  the  only  safeguard 
against  infection.^  The  following  schedule  ^  covers  in  a 
general  way  the  points  to  be  observed: 

'  Recently,  however,  the  Montclair,  N.  J.,  Board  of  Health  has 
adopted  a  requirement  that  all  persons  employed  in  the  manufacture 
or  handling  of  food  in  the  class  of  establishments  mentioned  in  this  sec- 
tion file  every  three  months  medical  certificates  of  freedom  from  evidence 
of  communicable  disease. 

2  Asbury  Park,  N.  J. 


MILK   AND   OTIIKR    I'OOI)    SUf'IM.FKS  403 

1.  Date  Hour 

2.  Street  and  No. 

3.  Name  of  Owner 

4.  Address 

5.  Name  of  Proprietor 

6.  Business 

7.  Are  foods  exposed  lo  flies,  dust  or  dirt? 

8.  Is  clothing  of  persons  handling  foods  clean? 

9.  Is  business  conducted  in  a  cleanly  manner? 

If  not  give  details 

10.  Construction  of  place  where  foods  are  sold  or  stored 

11.  Water-closet  and  lavatory  provided?  Are  they  sepa- 

rate from  room  where  foods  are  sold  or  stored? 
Condition 

12.  Are  cuspidors  provided?  Condition 

Any  disinfectant  used?  What? 

13.  Store  or  storeroom  used  as  a  dormitory? 

14.  Are  persons  handling  foods  in  good  health? 

15.  Remarks 

Inspector. 

The  above  points  should  be  covered  by  ordinance.  The 
greatest  importance  should  be  attached  to  cleanliness  of 
habits  and  methods  on  the  part  of  operatives.  All  such 
establishments  should  be  screened  during  the  fly  season. 
A  requirement  that  bread  be  wrapped  and  that  all  food  be 
properly  protected  against  handling,  dirt,  dust  and  flies 
during  transportation  and  while  on  sale  may  also  well 
be  adopted. 

Similar  remarks  apply  to  restaurants,  the  methods  in 
which  are  frequently  objectionable.  The  same  rules  and 
inspection  schedule,  with  any  necessary  changes,  may  be 
adopted. 

Attention  should  be  paid  to  markets,  especially  those 
in  which  produce  which  is  usually  eaten  without  peeling, 
paring  or  the  like,  or  cooking,  is  sold.  Such  produce,  em- 
bracing fruits  and  vegetables,  should  be  protected,  while 
on  display  or  in  transportation  or  storage,  against  flies  and 
other  contamination.  To  prevent  the  access  of  domestic 
animals,  they  should  be  kept  on  stands  two  and  a  half  feet 


404  A  MANUAL  FOR  HEALTH  OFFICERS 

or  more  above  the  ground.  To  attempt,  however,  to  en- 
force complete  protection  against  dust,  may  result  in  failure 
where  there  are  large  numbers  of  open-air  stands  and  mar- 
kets, although  the  health  authorities  should  have  power 
to  prevent  unquestionably  objectionable  contamination  of 
any  kind.  Confectionery,  pastry  and  beverages  should 
be  similarly  protected. 

At  soda  fountains  and  other  places  where  beverages  are 
sold,  cleanly  methods,  including  proper  washing  of  glasses, 
should  be  enforced  and  the  glasses  and  other  utensils  pro- 
tected from  fly  and  dirt  contamination.  Such  glasses  are 
in  a  true  sense  public  or  common,  are  used  many  times 
a  day  and  should  be  accordingly  strictly  looked  after. 
Special  attention  is  to  be  paid  to  the  rims,  which  experi- 
ment has  shown  may  harbor  numerous  germs,  and  an 
after-rinsing  in  clean  water  is  important.  It  would  be 
desirable  to  have  the  cleansing  take  place  within  sight  of 
the  customer  instead  of  in  the  dirty  tanks  not  infrequently 
found. 

Publicity.  —  Improvement  in  conditions  will  be  acceler- 
ated by  publicity  on  the  conditions  of  the  several  establish- 
ments. Score-cards  assist  in  this  regard.  The  success  of 
"consumers'  leagues"  in  publishing  white  lists  of  praise- 
worthy commercial  establishments  is  an  example  of  what 
can  be  accomplished  through  publicity. 

REFERENCES 

Wiley,  "  Foods  and  Their  Adulteration,"  1912. 

Edelmann,  "  A  Text-Book  of  Meat  Hygiene,  with  Special  Con- 
sideration of  Ante-mortem  and  Post-mortem  Inspection  of  Food- 
producing  Animals"  (translated  by  Mohler),  191 1.  (For  veterinary 
inspectors.) 

Rosenau,  "  Preventive  Medicine  and  Hygiene,"  1913,  sec.  HI, 
"  Foods." 

For  laboratory  references  see  Appendix  D. 


CHAPTER    IV 
WATER  SUPPLIES 

The  importance  of  the  purity  of  water  supplies  has  already 
been  sufficiently  indicated  in  Chapter  I.  There  it  was 
pointed  out  that  typhoid  fever  and  other  intestinal  dis- 
eases are  very  frequently  water-borne,  and  that,  through 
the  lowered  vitality  induced  in  those  who  survive  attacks 
of  typhoid,  tuberculosis  and  other  diseases  may  be  indirectly 
increased.  Even  infant  mortality  may  be  heightened  by 
polluted  water  supplies  through  its  being  given  to  infants 
to  drink  or  through  its  use  in  washing  bottles  and  other 
utensils. 

To  insure  the  degree  of  purity  demanded  in  water  for  the 
sake  of  safety  necessitates  not  only  careful  inspection  of 
sources  but  also,  from  time  to  time,  laboratory  analysis. 

INSPECTION 

In  the  first  place  a  great  deal  can  be  told  by  means  of 
inspection  alone.  Some  supplies  can  be  condemned  on 
inspection  alone,  and  recourse  to  the  laboratory  is  needless 
unless  to  obtain  extra  evidence  for  legal  proceedings.  On 
the  other  hand,  it  may  be  possible  through  inspection  to 
establish  a  certainty,  or  nearly  so,  that  a  supply  is  safe, 
although  confirmatory  analyses  should  be  made  in  impor- 
tant or  doubtful  cases. 

ANALYSIS 

I.  Bacteriological.  —  In  the  analysis  the  most  sensitive 
and   important   tests   are   the   bacteriological.^     Thus   the 

^  See  Prescott  and  Winslow,  "  Elements  of  Water  Bacteriology," 
1913- 

405 


4o6  A  MANUAL   FOR   HEALTFI  OFFICERS 

presumptive  tests  for  B.  coli  (the  "  colon  bacillus,"  indic- 
ative of  human  or  animal  pollution)  provide  a  searching 
means  of  gauging  the  sanitary  quality.  The  making  of 
frecjuent  B.  coli  tests  —  say  daily  —  would  alone  be  a 
fairly  satisfactory  check  on  a  supply.  The  total  count  of 
bacteria  should  also  be  periodically  obtained. 

2.  Chemical.  —  When  a  searching  study  of  a  supply  is 
to  be  made  or  confirmatory  evidence  to  be  secured,  then  it 
is  necessary  to  make  use  of  the  supplementary  means  of 
chemical  analysis.  While  the  bacteriological  results  furnish 
a  sensitive  picture  of  conditions  for  the  time  being,  the 
chemical  afford  something  in  the  way  of  interpretation  re- 
garding the  history  of  the  water.  This  is  due  to  the  fact 
that  the  chemical  traces  of  pollution  and  bacterial  action 
persist  long  after  the  bacteriological  indications  have  passed 
away,  so  that  the  exact  state  of  a  water  relative  to  its  past 
and  future  history  can  be  indicated  only  by  chemical 
methods. 

The  two  branches  of  analysis  complement  each  other, 
and  both  together  supplement  the  findings  of  inspection. 
The  more  important  the  case  in  hand  and  the  more  doubt 
involved,  the  more  extensive  and  detailed  must  be  the 
methods.  Laboratory  results,  as  may  be  inferred  from  the 
above,  cannot  be  interpreted  without  reference  to  inspec- 
tion. Where  the  laboratory  result  is  favorable  there  may 
still  be  threatening  conditions  to  be  perceived  on  inspection; 
while  if  it  is  unfavorable,  sources  of  contamination  should 
be  located  and  the  possibility  (or  impossibility)  of  their 
removal  be  ascertained. 

In  laboratory  work  on  water  the  standard  methods  of  the 
Laboratory  Section  of  the  American  Public  Health  Associa- 
tion should  be  followed.^ 

3.  In  addition  to  the  above  tests  it  is  sometimes  neces- 
sary to  make  microscopic  examhiations  for  the  detection 
of    the    minute    animal    and    plant    organisms    to    which 

*  See  references,  Appendix  D. 


WA'IM'IK    SIJI'I'IJFOS  407 

arc  due  various  tastes  and  (>flf)rs  which  oauv  in  water 
supplies.' 

Lead  Poisonin(;  from  Water.  —  Certain  waters  dissolve 
the  lead  of  pipes,  producing  chronic  lead  poisoning  in  the 
consumers.  A  great  deal  of  lead  piping  is  in  use,  even  in 
modern  plumbing  work,  and  since  lead-dissolving  waters 
are  not  uncommon,  it  is  probable  that  there  are  considerable 
numbers  of  undetected  cases  of  such  poisoning.  Even  short 
lengths  of  lead  pipe  may,  under  favorable  circumstances, 
produce  the  poisoning.  Lead  is  a  cumulative  poison, 
and  even  minute  quantities  taken  successively  are  dan- 
gerous. "The  purest,  softest  and  best  aerated  w^aters  are 
especially  prone  to  act  upon  lead"  (Roscnau).  Turljid 
waters  and  hard  waters  are  less  apt  to  do  so.  "Water 
artificially  charged  with  carbon  dioxide,  however,  readily 
dissolves  lead,  so  that  lead  piping  and  fittings  in  soda  water 
fountains  and  in  syphon  bottles  are  dangerous.  Beverages 
containing  free  acid  may  also  dissolve  it;  the  historic 
poisoning  of  Devonshire  cider  through  the  use  of  lead  piping 
is  an  instance  in  point.  Chemical  tests  will  not  determine 
whether  or  not  a  water  will  dissolve  lead ;  suspected  water 
should  be  examined  for  lead  in  samples  taken  under  practi- 
cal conditions.  No  w^ater  which  contains  even  a  trace  of 
lead  should  be  used  for  drinking  purposes.^ 

In  connection  with  water  supplies  there  are  also  con- 
siderations other  than  the  sanitary, — as,  for  example,  proper 
chemical  composition  for  household  and  manufacturing 
uses,  adequacy  for  fire  protection,  etc.^ 

^  Whipple,  "  Microscopy  of  Drinking  Water,"  is  the  standard  work 
on  this  subject. 

^  For  further  particulars  see  Rosenau,  "  Preventive  Medicine  and 
Hygiene,"  1913,  pp.  751,  810  ff. 

^  For  discussion  of  sanitary-  and  other  aspects  see  Hazen,  "  Clean 
Water  and  How  to  Get  It  ";  Whipple,  "  The  Value  of  Pure  W^ater  "  (in 
which  monetary  values  for  the  various  qualities  of  water  supplies  are 
worked  out  and  combined  in  a  formula),  and  Turneaure  and  Russell, 
"  Water  Supplies." 


4o8  A  MANUAL   FOR   HEALTH  OFFICERS 

PUBLIC    WATER    SUPPLIES 

Upon  health  authorities  devolves  the  responsibility  of 
supervision  over  the  sanitary  character  of  public  water 
supplies.  While  much  of  the  power  necessary  to  secure 
protection  of  such  supplies  may  rest  with  water  boards  and 
municipal  councils,  the  sanitary  authorities*  should  exer- 
cise constant  oversight,  making  known  their  findings  to 
the  proper  authorities  from  time  to  time.  This  places  the 
responsibility  for  taking  direct  action  upon  the  water 
authorities  in  cases  where  it  does  not  rest  with  the  health 
department. 

There  are  two  general  classes  of  water  supplies: 

1.  Impounded  surface  water  supplies. 

2.  Ground  water  supplies  from  springs  or  driven  wells. 
We  shall  consider  first  the  former. 

I.  Surface  Supplies  are  subject  to  pollution:^  (i)  from 
sewage  and  human  excreta;  (2)  from  animal  sources;  and 
(3)  from  trades  and  household  (other  than  sewage)  wastes 
and  the  like.  Besides  these  there  may  be  various  contami- 
nations of  a  less  serious  character. 

Naturally,  the  most  important  class  is  pollution  from 
human  sources,  which  sooner  or  later  means  actual  infection. 
Here  the  principal  sources  of  pollution  are  sewage  outfalls 
and  drains,  privies  and  the  dumping  of  nightsoil  where  it 
may  drain  into  the  supply.  The  situation  of  habitations 
and  camps  on  watersheds  is  always  more  or  less  of  a  menace, 
and  where  a  watershed  is  open  to  public  access,  pollution 
may  be  caused  by  persons  passing  through  it,  by  sports- 
men, picnickers  and  the  like.  A  single  case  of  typhoid 
fever  on  a  watershed  may  cause  a  great  epidemic  of  the 

1  Distinction  should  be  made  between  (i)  "  contamination,"  which 
denotes  the  access  of  objectionable  foreign  matter  to  the  water,  (2) 
"  pollution,"  a  stronger  term,  usually  implying  access  of  sewage  matters, 
and  (3)  "  infaction,"  which  denotes  the  actual  presence  of  pathogenic 
organisms. 


WATER  SUPPLIES  409 

disease  among  the  users  of  the  supply,  as  was  the  case  in 
the  Plymouth  epidemic  (see  Chapter  I)  and  others.  Since 
it  is  practically  impossible  to  guard  against  carriers  and 
unrecognized  cases,  the  only  safe  course  is  to  regard  all 
human  excreta  as  a  source  of  infection.  Where  construc- 
tion camps  are  located  on  a  watershed  the  situation  calls 
for  the  strictest  measures;  where  it  is  necessary  to  tolerate 
such  camps  the  arrangements  for  sanitary  disposal  of  ex- 
creta must  be  perfect.  Even  so  it  is  not  always  certain 
that  random  pollutions  of  soil  and  streams  may  not  take 
place.  It  would  be  well,  where  laborers  are  employed  on 
watersheds,  to  require  that  they  be  subject  to  the  Widal 
test  before  being  accepted  and  receive  typhoid  inoculation.^ 
Trains  passing  through  watersheds  may  distribute  pollu- 
tion, as  was  the  case  in  epidemics  at  Scran  ton,  Pa.,  and 
elsewhere.  Such  is  the  danger  unless  the  drainage  from 
railroad  tracks  is  diverted  from  water  supplies,  until  some 
form  of  sewage  receptacle  is  attached  to  trains. 

Animal  pollution  —  which,  however,  is  usually  of  sec- 
ondary importance  —  may  be  produced  by  stables,  pig- 
styes,  live  stock  wading  in  streams  and  pasturing  on  land 
draining  into  the  streams,  manured  fields,  roads,  etc. 
Some  such  pollution  always  takes  place  where  supplies  are 
drawn  from  inhabitated  areas. 

Trades  and  household  wastes  are  of  various  kinds  and 
more  or  less  objectionable. 

2.  Ground  Water  Supplies  are  subject  to  pollution 
through  the  seepage  of  sewage  and  sometimes  through 
breakage  of  pipes  and  other  accidents  which  permit  the 
access  of  polluted  ground  water.  The  possibility  of  pollu- 
tion of  aqueducts  and  the  like  by  laborers  is  not  to  be 
forgotten.  It  is  customary  to  store  ground  water  sup- 
plies, which  are  rich  in  nitrate  plant  food,  in  covered 
reservoirs,  otherwise  the  access  of  light  permits  the  develop- 
ment of  vegetable  growths  which,  while  not  materially 
^  Am.  Jour.  Pub.  Health,  1913,  vol.  Ill,  no.  4,  p.  390. 


4IO  A  MANU.\L   FOR  HEALTH   OFFICERS 

detrimental  to  health,  impart  disagreeable  tastes  and 
odors  to  the  water. 

Reservoirs  should  be  safeguarded  on  the  same  principles 
as  surface  watersheds,  but  e\'en  more  strictly.  Boating, 
bathing,  fishing,  skating  and  the  access  of  persons  to 
the  shores  should  be  prohibited  because  of  the  danger  of 
incidental  pollutions  through  depositing  of  excreta  in  or 
near  the  water,  spitting  and  other  contamination.^  An- 
other argument  to  this  effect  is  that  persons  sometimes 
drown  in  such  bodies  of  water  and  that  to  recover  bodies 
may  necessitate  empt^'ing  the  entire  supply  or,  in  winter, 
when  persons  may  break  through  the  ice,  waiting  until  the 
ice  disappears.  Such  rules  as  the  above  curtail  the  freedom 
of  comparatively  few  people  for  the  obvious  protection  of  a 
whole  community. 

Even  when  a  water  supply  is  subject  to  purification  by 
filtration  or  otherwise,  pollution  should  so  far  as  possible 
be  avoided,  for  the  reasons,  that  increased  pollution  makes 
a  water  more  difficult  and  expensive  to  purify,  and  that  in 
case  of  possible  accident  to  purification  works  there  will  be 
increased  danger  of  epidemic. 

Purification  Methods.  —  Where  it  is  necessary  to  make 
use  of  water  supplies  which  would  be  unsafe  in  their  ra.w 
state,  some  form  of  bacterial  purification  must  be  resorted 
to.  This  is  a  problem  for  the  sanitary  engineer.  The  fol- 
lowing are  the  classes  of  methods  in  use: 

I.  Storage.  —  When  a  contaminated  water  is  held  for  a 
numl)er  of  days  in  a  storage  reservoir,  a  gradual  purification 
process  takes  place.  This  consists  in  the  settling  out, 
through  sedimentation  (natural  or  aided  with  chemicals), 
of  suspended  matters  (among  which  many  of  the  micro- 
organisms present),  and  through  the  natural  perishing  of 
bacteria  in  what  is,  to  those  of  animal  origin,  an  adverse 
environment.  This  is  the  process  which  takes  place,  to  a 
greater  or  less  degree,  in  all  reservoirs  where  water  remains 
^  Jour.  Am.  Pub.  Health  Assn.,  191 1,  vol.  I,  no.  9,  p.  671. 


WATKk    SUf'IMJKS  4tr 

for  days  at  a  time.  Sloraj^e,  or  scdimenlalion,  is  a  IcKili- 
mate  mode  of  purilicatiou  which  may  he  siinicicnL  f(;r  some 
supplies  where  (he  amount  (A  origiiial  prjllutifjn  was  sHj^ht 
and  where  long  periods  can  be  ensured,  hut  in  most  in- 
stances it  is  a  preliminary  to  more  exactly  governahle 
means.  The  reason  that  it  cannot  he  relied  upon  entirely 
in  most  instances  is  that  it  is  not  always  certain.  For 
example,  currents  may  he  set  up  in  a  hody  of  water  \)y 
temperature,  wind  or  otherwise,  which  will  permit  the 
passage  of  polluted  water  pretty  directly  to  the  intake. 
Again,  while  sufficient  at  times,  at  other  times  it  may  not 
be  adequate  to  take  care  of  fluctuations  in  pollution. 
Finally,  it  may  be  sufficient  during  periods  of  little  move- 
ment of  water,  hut  when  rainfalls  come  — ■  particularly 
following  a  drought  — -  great  quantities  of  polluted  water 
may  pass  through  the  reservoirs  with  insufificient  or  no 
sedimentation. 

The  all-important  factor  in  sedimentation  is  time.  Con- 
trary to  what  is  popularly  supposed,  bacterial  purification 
takes  place  in  quiet  water,  not  in  running  streams,  in  which 
the  sediment  and  bacteria  are  kept  stirred  up.  In  the 
latter  case  aeration  may  take  place  and  the  water  may  be 
rendered  more  agreeable  to  the  senses,  but  the  more  rapid 
the  stream  the  more  dangerous  it  is  as  a  possible  carrier 
of  pollution  from  its  frequently  far-distant  sources.  The 
amount  of  time  necessary  for  purification  by  sedimentation 
must  he  determined  in  each  case  by  experiment  and  bac- 
teriological study  under  local  conditions.  In  many  in- 
stances thirty  days  or  more  may  be  required  to  render  a 
water  safe,  but  no  definite  rule  can  be  laid  down. 

2.  Filtration.  —  Filtration  is  of  two  kinds:  (i)  slow 
sand  filtration,  in  which  the  water  passes  slowly  under  a 
small  head  through  large  beds  of  fine  sand,  on  the  surface 
of  which  accumulates  a  "  schmutzdecke "  or  organic  layer 
which  plays  the  principal  part  in  the  retention  of  bacteria ; 
and    (2)   mechanical  filtration,   in  which   the  water,   after 


412  A   MANUAL   FOR   HEALTH  OFFICERS 

hcuing  a  cliciiiical  coagulant  added  to  it,  passes  rapidly 
under  a  larger  head  through  la>crs  of  sand  in  filter  machines. 
Satisfactory  results  ma>-  be  obtained  with  both  processes, 
which,  however,  dilTer  in  the  skill  required  for  operation, 
the  original  and'opcrating  costs  and  the  space  occupied.^ 
Filtration  plants  should  be  designed  and  built  by  competent 
sanitary  engineers  and  operated  under  expert  supervision 
and  constant  bacteriological  control. 

3.  Disinfection.  —  A  comparatively  recent  method 
of  water  purification  consists  in  chemical  treatment,  the 
principal  substance  used  for  this  purpose  being  chlorinated 
lime  (bleaching  powder,  "chloride  of  lime  ").2  This  sub- 
stance has  been  used  for  years  in  the  disinfection  of  sewage 
and  now  has  been  applied  with  success  in  the  treatment  of 
waters  which  are  somewhat  polluted  and  in  which  there  is 
not  too  much  turbidity  or  organic  matter.  It  is  particu- 
larly valuable  as  an  emergency  measure.  The  amount  of 
the  substance  necessary  varies  according  to  the  composition 
of  the  water,  the  more  being  required  the  greater  the 
amount  of  organic  matter  present.  Experiment  has  shown 
that  waters  are  rendered  practically  sterile  by  the  addition 
of  amounts  of  chlorinated  lime  (estimated  as  available  chlo- 
rine) ranging  from  o.i  to  5  parts  per  1,000,000  parts  of 
water  (Rosenau). 

In  public  water  supplies,  where  the  treatment  is  used 
regularly,  an  average  of  from  5  to  12  pounds  per  million 
gallons  is  applied.  Expert  supervision  and  bacteriological 
control  are  essential.  Care  should  be  taken  that  the 
hypochlorite  used  is  up  to  standard  —  say  30  per  cent  or 
more  of  available  chlorine.  Twenty-five  to  50  per  cent 
more  than  absolutely  necessary  to  practically  sterilize  is 
usually  applied  in  order  to  guard  against  fluctuations  in  the 
composition  of  the  water.     The  substance  is  not  expensive, 

1  See  Hazen,  "  Filtration  of  Public  Water  Supplies."     (Cf.  Rosenau, 
"  Preventive  Medicine  and  Hygiene,"  1913,  sec.  VI,  Chap.  V.) 
''  Liquid  chlorine  is  also  now  available. 


WATER   SUPPLIES  413 

is  practically  harmless  and  amounts  of  less  than  25  {)ouik1s 
per  million  gallons  arc  not  detcctiblc  by  the  senses.' 

Ozone  has  also  been  successfully  employed  for  the  same 
purpose  in  a  number  of  instances,  but  chlorinated  lime  is 
cheaper  and  simpler. 

Water  purification  in  general  is  an  art  ref|uiring  the  con- 
sideration of  many  circumstances  and  frccjucntly  the  com- 
bination of  different  methods.  The  above  remarks  are 
intended  merely  as  an  indication  of  the  broad  principles  of 
the  subject.  Details  arc  to  be  left  to  the  expert  judgment 
and  supervision  of  professional  sanitary  engineers,  bac- 
teriologists and  chemists. 

Official  Responsibility  for  the  purity  of  public  water 
supplies  rests,  according  to  local  conditions  and  laws,  with 
local  health  authorities,  with  state  authorities,  or  with 
both.  Properly  the  supervision  of  the  sanitary  character 
of  the  various  local  public  supplies  should  be  vested  in  an 
expert  division  of  the  state  department  of  health,  which 
should  also  have  control  of  public  water  supplies  and  sew- 
age disposal  throughout  the  state.  Otherwise  difficulty 
will  be  experienced  in  the  control  of  sources  located  in  or 
affected  by  districts  other  than  those  which  they  supply. 
In  a  few  instances  (e.g.,  the  Metropolitan  Water  and  Sew- 
erage District  of  Boston  and  neighboring  municipalities) 
several  communities  have  united  in  the  establishment  and 
control  of  common  supplies. 

In  one  case  at  least  it  has  been  judicially  decided  that  a 
municipality  is  legally  liable,  in  the  event  of  its  negligence, 
for  the  damages  from  typhoid  fever  and  other  sickness 
caused  by  a  polluted  public  water  supply .^ 

^  See  Hooker,  "Chloride  of  Lime  in  Sanitation,"  John  Wiley  and  Sons, 
Inc.,  1913,  p.  16;  Rosenau,  "  Preventive  Medicine  and  Hygiene," 
1913,  pp.  797,  1019;  TuUy,  "A  Stud}' of  Calcium  Hypochlorite  as  a  Dis- 
infectant of  Water,"  Am.  Jour.  Pub.  Health,  1914,  vol.  IV,  no.  5,  p.  423. 

*  Minnesota,  see  Am.  Jour.  Pub.  Hyg.,  1910,  p.  912;  191 1,  p.  146. 


414  A  MANUAL   FOR   HEALTH  OFFICERS 

PRIVATE   WATER   SUPPLIES 

In  small  or  rural  coniniunitirs  where  public  supplies  do 
not  exist,  recourse  must  he  had  lu  private  or  semi-public 
wells,  sprint;s  and  streams  as  sources  of  supply,  and  even 
after  a  public  supply  has  been  introduced  the  use  of  such 
private  supplies  continues  to  a  greater  or  less  extent. 
Since  such  private  or  semi-pul)lic  sources  are  freciuently 
polluted  and  present  difficult  problems  of  supervision  in 
growing  urban  or  semi-urban  communities,  their  use  should, 
in  the  presence  of  a  safe  public  supply,  be  strongly  dis- 
couraged. In  places  possessing  wells  and  privies  in  close 
proximity  to  one  another,  dangerous  pollutions  are  always 
to  be  looked  for.  Private  supplies  should  be  supervised, 
not  only  to  safeguard  the  health  of  families  possessing  them 
but  also  because  they  are  frequently  used  by  numbers  of 
people  from  neighboring  families  on  account  of  their  cool- 
ness, supposed  superior  quality,  etc.  The  Broeid  Street  pump 
epidemic  of  cholera  in  London  in  1854  is  a  case  in  point. 

What  has  been  said  as  to  the  pollution  of  public  surface 
water  supplies  applies  also  to  streams,  ponds  and  the  like 
which  are  used  in  a  private  or  semi-public  manner  and  need 
not  be  repeated.  The  subject  of  wells  and  springs  requires 
some  further  remark. 

The  requirements  for  a  safe  well  or  spring  supply  are: 

1.  That  it  he  in  itself  a  safe  source;  and 

2.  That  it  be  protected  by  proper  construction  from  possible 
contamination. 

I.  Inspection.  —  In  the  inspection,  first  the  possibility 
of  subsurface  pollution  is  to  be  considered.  In  the  absence 
of  knowledge  as  to  the  subsoil  and  ground  water  from  which 
the  supply  is  drawn,  a  wide  margin  of  safety  should  be 
allowed.  The  ordinary  sources  of  pollution  —  privies, 
cesspools,  drains,  barnyards,  etc.  —  should  be  looked  for. 
Leaky  and  broken  drains  are  not  uncommon.  While 
sources  of  water  that  are  located  uphill  from  possible  sources 


WATER   SUPPLIES  4^5 

of  pollution  arc  in  general  safer  llian  (liosc-  which  are  lower 
down,  this  is  not  always  the  case,  f(;r  the  i,M-oiind  water  level 
may  slope  in  the  opposite  direction.  Again,  rifts  and  under- 
ground streams  may  exist  in  rocky,  hard  or  clayey  soils, 
conveying  pollution  from  relatively  distant  points.  In 
sandy  soil  natural  purification  of  sewage  may  take  place, 
but  this  cannot  be  determined  by  inspection  alone,  and, 
unless  proved  by  laboratory  examination,  cannot  be  relied 
upon,  particularly  where  the  soil  has  long  been  saturated 
with  pollution.  Depth  must  be  considered;  deep  driven 
wells  are  of  course  less  liable  to  pollution  than  the  shallow 
dug  kind.  No  hard  and  fast  rules  for  inspection  can  be 
laid  down  to  cover  all  circumstances.  In  general,  however, 
possible  sources  of  sewage  pollution  within,  say,  lOO  feet  or 
so,  should  be  regarded  with  more  or  less  suspicion.  Privies 
within  suspicious  distance  should  be  of  the  sanitary  type, 
with  water-tight  pits  or  receptacles  which  are  regularly 
cleaned  out  and  contents  removed  to  a  safe  point.  Nearby 
cesspools  should  be  water-tight. 

For  the  detection  of  underground  pollution  in  suspicious 
cases  the  use  of  dye  is  to  be  recommended.  That  known  as 
uranin,  which  may  be  procured  from  any  chemical  supply 
house,  is  as  good  as  any.  Some  of  the  dye  is  sprinkled 
in  the  cesspool  or  other  suspected  source  of  pollution, 
thoroughly  mixed  into  the  whole  body  of  the  liquid,  and 
then  some  time  allowed  for  the  color  to  appear  in  the  water 
supply  under  observation.  In  some  cases  it  may  be  neces- 
sary to  make  observations  and  repeated  tests  for  several 
weeks  before  reaching  a  negative  conclusion.  Not  a  great 
deal  of  the  dye  need  be  used,  and  its  appearance  in  an 
effluent  in  even  minute  quantities  is  readily  detected. 
Uranin  imparts  a  peculiar  and  very  characteristic  fluores- 
cent or  opalescent  tinge  to  the  water  which  is  seen  when  a 
little  of  the  liquid  is  taken  in  a  glass.  If  the  dye  comes 
through  the  soil  it  may  be  presumed  that  bacteria  may  also 
do  so;   if  the  result  is  negative  it  should  be  confirmed  bac- 


4l6  A  MANUAL  FOR  HEALTH  OFFICERS 

teriologically  and  chemically.  The  test  is  not  a  substitute 
for  bacteriological  examination,  but  may  be  used  in  con- 
junction with  the  latter  and  is  useful  in  indicating  sources 
of  pollution.  Also,  it  may  be  readily  available  when  the 
bacteriological  method  is  not. 

Surface  contamination  should  then  be  looked  for.  Very 
frequently  wells  and  springs  permit  the  entrance  of  surface 
drainage  in  time  of  rain  with  the  resultant  washing  in  of 
extraneous  and  dangerous  or  at  least  detrimental  matter. 

2.  Laboratory  Analysis  should  be  resorted  to  in  cases  of 
doubt.  It  need  not,  however,  be  applied  to  those  cases 
where  there  is  no  reason  for  suspecting  contamination,  nor, 
on  the  other  hand,  where  the  contamination  is  so  evident 
that  no  laboratory  proof  is  needed. 

Protective  Construction.  —  When  a  supply  is  presumed 
to  be  originally  of  good  quality  attention  should  be  paid  to 
protective  construction.  Dug  wells  should  be  properly 
lined  with  stone  or  brick  and  should  be  surrounded  at  the 
surface  with  a  top  casing  of  cement,  extending  down  the 
outside  of  the  lining  to  a  depth  of  one  or  two  feet,  rising 
above  the  surface  of  the  ground  say  six  inches  or  more,  and 
sloping  away  all  around  for  a  foot  or  two,  so  as  to  ward  off 
surface  water  from  the  mouth  of  the  well.  The  covering 
should  be  entirely  water-tight,  and  the  passage  of  the  pipe 
for  the  pump  should  be  through  a  tight  joint.  Open-mouth 
wells  are  liable  to  more  or  less  contamination.  Similar 
principles  apply  to  protective  construction  for  driven  wells 
and  springs. 

Rural  and  Urban  Supplies  Compared.  —  In  rural 
districts,  private  wells  and  springs  are  the  natural  and  only 
available  sources  of  supply,  and  may  be  properly  super- 
vised. In  closely  settled  communities,  however,  good 
public  supplies  should  be  adopted  and  all  private  supplies 
looked  upon  with  great  suspicion.  Chances  of  pollution 
from  privies,  drains  and  sewers  become  numerous,  and 
supervision  of  private  sources  of  supply  is  such  a  dil^cult 


WATKK    SUI'f'LlKS  417 

and  unsatisfactory  matter  that  the  health  officer  is  justificfl 
in  endeavoring  to  abolish  all  that  are  in  any  way  open  to 
suspicion. 

Procedure  to  Abolish  Wells,  etc.  —  The  usual  procedure 
is  to  secure  evidence,  from  inspection  and,  if  necessary, 
from  analysis,  that  the  well  (or  spring)  is  an  unfit  source  of 
supply,  and  then,  acting  under  ordinance,  serve  an  order 
entirely  to  abolish  or  to  clovse  the  source.  In  the  latter  case 
the  pump,  if  there  is  one,  should  be  removed.  Caution 
should  be  taken  that  the  supply  is  not  opened  up  again 
later,  in  the  event  of  which  strict  action  should  be  taken. 
In  most  instances  such  sources  can  readily  be  abolished  by 
an  order  accompanied  by  an  explanation  that  the  water 
is  deemed  dangerous  to  health.  Attempting  to  purify  or 
disinfect  wells  is  not  advisable  except  in  those  few  in- 
stances where  the  contamination  is  temporary  and  from 
the  surface  and  its  source  can  readily  be  removed ;  in  such 
instances  it  may  be  possible  to  treat  the  water  with  a 
quantity  of  freshly  burned  lime  or  chlorinated  lime  (in  the 
latter  case  enough  to  make  a  i  per  cent  solution)  and  then 
pump  the  well  out  several  times.^  But  the  general  rule  is 
abolition  or  abandonment. 

Oversight  should  be  exercised  so  far  as  possible  over 
bottled  waters  on  the  market,  as  well  as  over  the  sources  of 
water  used  for  the  manufacture  of  carbonated  beverages, 
both  as  to  source  and  as  to  methods  of  handling  and  of  cleans- 
ing of  bottles.  The  best  water-bottling  plants  practice 
sterilization  of  bottles  and  containers  and  other  precautions. 

Supplies  of  water  for  dairy  purposes  should  receive 
special  attention.^ 

^  See  Rosenau,  "  Preventive  Medicine  and  Hygiene,"  IQ13,  p.  1034. 

2  See  Prescott,  "  Farm  Water  Supplies,  with  Special  Reference  to 
Dairy  Farms,"  Am.  Jour.  Pub.  Health,  1913,  vol.  Ill,  no.  9,  p.  892; 
Fuller,  "  Underground  Waters  for  Farm  Use  "  (of  general  interest  on 
wells,  etc.),  Paper  No.  255  U.  S.  Geol.  Surs-ey;  Fuller,  "  Domestic  Water 
Supplies  for  the  Farm,"  John  Wiley  and  Sons,  Inc.,  New  York,  1912. 


4l8  A  MANUAL   FOR   HEALTH  OFFICERS 

REFERENCES 

Hazen,  "  Clean  Water  and  How  to  Get  It,"  John  Wiley  and  Sons, 
Inc.,  New  York. 

Rosenaii,  "  Preventive  Medicine  and  Hygiene,"  1913,  sec.  VI. 

Turneaure  and  Russell,  "  Public  Water  Supplies,"  John  Wiley  and 
Sons,  Inc.,  New  York. 

Whipple,  "  The  Value  of  Pure  Water,"  John  Wiley  and  Sons,  Inc., 
New  York. 

On  the  sanitary  engineering  of  private  water  supplies  in  rural  or  semi- 
rural  districts: 

Gerhard,  "  Sanitation,  Water  Supply,  and  Sewage  Disposal  of 
Country  Houses,"  and  Bashorc,  "  Sanitation  of  a  Country  House." 

For  laboratory  references  see  Appendix  D. 

ICE  SUPPLIES 

The  subject  of  ice  supplies  need  not  detain  us  long. 
Bacteriologists  agree  that  ice  is  greatly  purified  in  freezing, 
and  still  further  purified  in  storage.  Epidemiological 
records  fail  to  disclose  that  ice  is  of  any  particular  impor- 
tance in  the  spread  of  typhoid  fever  and  other  water-borne 
diseases  even  though  in  many  instances  ice  is  doubtless  cut 
from  polluted  sources.  The  best  known  epidemic  which 
has  been  attributed  to  ice  is  that  of  Ogdensburg,  N.  Y.^ 
The  U.  S.  H>gienic  Laboratory  (Bull.  No.  35)  after  an 
exhaustive  study  of  typhoid  fever  in  the  District  of  Co- 
lumbia concluded  that  "ice  plays  little,  if  any,  part  in 
spreading  the  infection  in  the  District  of  Columbia."  Hill, 
speaking  particularly  of  natural  ice,  states  that  there  is  no 
evidence  for  supposing  that  over  TuVir  of  i  per  cent  of  the 
water-borne  typhoid  cases  can  be  attributed  to  that  source, 
and  considers  this  figure  an  exaggeration.  While  it  cannot 
be  denied  that  ice  may,  under  unusual  circumstances,  when 
taken  from  a  polluted  source  and  used  without  much  delay, 
act  as  a  vehicle  of  disease,  still  "no  considerable  amount  of 
disease  has  ever  been  satisfactorily  traced  to  ice,"  and  it 

1  Recently,  however.  Dr.  H.  W.  Hill  has  studied  the  evidence  in  this 
case  with  the  conclusion  that  it  is  contraindicati\"e  of  ice  as  the  real 
source.     (Natural  Ice  Assn.  paper;  see  below.) 


WATKR    SUPPF.rilS  419 

"is  plainly  far  less  dangerous  to  the  puMic  licaltli  than  is 
either  water  or  milk"  (Sedgwick).' 

Natural  ice  profits  by  storage,  an  important  protective.- 
factor,  in  addition  to  purification  by  freezing.  The  chief 
danger  here  is  that  particles  of  sewage  and  bacteria  may  be 
enmeshed  in  the  ice  in  the  process  of  freezing,  as,  for  ex- 
ample, when  polluted  water  overflows  the  ice  sheet.  With 
artificial  ice,  any  such  matters  present  (either  in  the 
water  supply  or  derived  from  contamination  in  process  of 
manufacture)  would  be  frozen  in;  further,  the  product  is 
consumed  with  little  or  no  storage;  actually,  however,  the 
danger  from  artificial  ice  appears  to  be  very  small  indeed. 
Ice  is  low  in  bacteria  and  mineral  matter  and  may  well  be 
used,  through  melting,  for  drinking  purposes  where  a  very 
soft  pure  water  is  desired. 

Some  degree  of  supervision  is,  of  course,  advisable,  for 
there  is  just  enough  evidence  to  show  that  ice  may  some- 
times act  as  a  vehicle  of  disease.  Such  supervision  consists 
in  licensing  dealers,  inspecting  sources  to  see  that  plainly 
polluted  water  supplies  are  not  used  (with  tests  of  such 
supplies  in  doubtful  cases),  and  ensuring  that  contamina- 
tions do  not  take  place  in  manufacture  or  handling.  Also, 
while  ice  tends  to  cleanse  itself  in  melting  and  washing  off, 
there  are  instances  where  in  placing  in  water  tanks  it  is 
handled  with  unclean  hands,  and  in  this  way  and  by  other 
such  obvious  possibilities  drinking  water  supplies  may  at 
times  become  contaminated. 

^  See  the  papers  by  Sedgwick,  Hill,  Rosenau,  Winslow,  Jordan, 
Whipple,  Porter,  Sparks  and  others,  published  by  the  Natural  Ice 
Assn.  of  America,  116  Nassau  St.,  New  York  City.  A  summary  of  the 
few  epidemics  which  have  been  attributed  to  ice  is  given  by  Rosenau, 
"  Preventive  Medicine  and  Hygiene,"  1913,  pp.  840-42. 


CHAPTER   V 
HOUSING   AND    INDUSTRIAL   HYGIENE 

The  term  "housing"  in  its  broadest  sense  includes  con- 
ditions in  ordinary  dweUing  houses,  in  factories,  schools, 
public  buildings,  and  in  fact  in  any  kind  of  habitation. 
As  a  rule,  however,  it  is  applied  more  particularly  to 
dwelling  houses,  while  factory  sanitation,  school  sani- 
tation, etc.,  are  considered  as  separate  subjects.  In  the 
present  chapter  we  shall  treat  the  subject  in  this  more 
particular  sense  and  shall  moreover  omit  any  discussion 
of  conditions  outside  of  the  dwelling.  Such  surrounding 
conditions  will  be  considered  in  the  next  chapter,  under 
the  head  of  nuisances,  while  for  the  present  we  deal  with 
those  exclusively  interior. 

The  immediate  environment  of  persons  in  their  homes 
and  places  of  ordinary  occupation  is  obviously  one  of  the 
most  important  objects  of  sanitary  supervision.  Vitality 
is  depressed  and  thus  disease  of  all  kinds  — -  most  con- 
spicuously tuberculosis  —  is  favored  by  bad  dwelling  con- 
ditions, and  through  congestion,  filth  and  dirty  habits  the 
routes  of  transmission  of  communicable  disease  are  many 
and  direct.  On  the  other  hand  the  improvement  of  this 
class  of  conditions  is  one  of  the  most  formidable  problems 
with  which  health  authorities  are  confronted,  because  of 
the  fact  that  they  are  interwoven  not  only  with  established 
structural  conditions  but  also  —  and  even  more  important 
—  with  strongly  entrenched  habits  and  attitudes  on  the 
part  of  the  people  themselves.  Hence  the  campaign  must 
involve  persistent  popular  education  for  results  which, 
while  far-reaching,  will  come  but  gradually. 

420 


HOUSINC;   AND    [NDUSTRfAf.    HYCiTHNK  421 

HOUSING 

Housing  questions  deal  not  only  with  hygiene  but  also 
with  safety  in  construction,  protection  against  fire,  economic 
and  social  conditions,  and  other  factors,  mention  of 
which  must  necessarily  be  omitted  here,  although  they 
enter  into  every  broad  view  of  the  subject.  The  following 
are  the  chief  hygienic  considerations: 

1.  Congestion.  —  The  unsanitary  conditions  attendant 
on  overcrowding  are  obvious.  Opportunities  for  trans- 
mission of  disease  by  contact  are  increased,  while  the 
factors  of  uncleanliness,  bad  ventilation,  and  the  like 
(mentioned  below)  are  favored.  Community  congestion 
means  the  crowding  of  dwellings  into  a  limited  area  of 
land,  the  building  of  tenements,  the  cutting-off  of  light  and 
air,  and  other  disadvantages.  Even  more  important  is 
family  congestion,  which  results  in  room  overcrowding  with 
a  long  train  of  attendant  evils.^  While  there  are  economic 
and  other  conditions  at  work  which  make  the  remedying 
of  congestion,  and  even  its  prevention,  an  exceedingly 
difficult  administrative  problem,  the  health  authorities 
have  certain  clear  duties  to  perform  in  restricting  the  num- 
ber of  persons  who  may  occupy  a  certain  air-space,  in 
placing  restrictions  on  the  construction  of  new  buildings 
and  requiring  necessary  alterations  of  old  ones,  and  the 
like. 

2.  Uncleanliness.  — This  is  an  even  more  undesirable 
factor  than  overcrowding,  particularly  in  regard  to  the 
dissemination  of  disease  by  contact.  It  is  doubtless  true, 
also,  that  uncleanliness  and  obnoxious  conditions  do  in 
themselves  exert  a  depressing  effect  —  both  directly  and 
through  psychological  reaction  —  on  the  human  organism, 
especially  in  the  case  of  infants  and  the  less  robust  adults. 

3.  Lack  of  Proper  Ventilation,  Light,  etc.  —  Under 

^  Veiller,  "Room  Overcrowding  and  the  Lodger  Evil,"  National 
Housing  Assn.  Publications,  no.  18. 


422  A  MANUAL   FOR  HEALTH  OFFICERS     . 

this  head  we  group  a  number  of  remaining  conditions  of 
which  the  chief  refer  to  ventilation.  The  lack  of  light 
has  more  of  an  indirect  than  a  direct  effect,  in  favoring 
uncleanliness  and  in  being  usually  accompanied  by  faulty 
ventilation.  Light  itself,  however,  has  some  (though  not  a 
great  practical)  value  as  a  germicide.  Such  are  the  reasons 
for  the  forbidding  of  the  dark  rooms  which  unfortunately 
are  so  often  found  in  present  day  tenements. 

In  all  of  tlie  above  factors  it  will  be  seen  that  the  manner 
in  which  people  live  is,  without  belittling  the  importance 
of  proper  dwellings  and  the  providing  of  decencies  and 
conveniences,  of  even  greater  consequence.  Hence  the 
necessity  of  raising  standards  of  living  through  education, 
particularly  popular  instruction  in  the  home.  A  great 
deal  can  be  done  in  this  direction  by  the  public  health 
nurses  employed  for  tuberculosis  and  infant  hygiene  work. 
Proper  school  instruction  in  hygiene  will  also  accomplish  a 
great  deal. 

Plumbing  Inspection.  —  Present-day  sanitary  science  has 
dispelled  traditional  ideas  as  to  the  importance  of  plumb- 
ing inspection  from  the  standpoint  of  health.  Distinction 
must  be  made  between  disposal  of  excreta,  which  is  of 
prime  importance  to  health,  and  the  practically  negligible 
dangers  from  sewer  gas.  (Cf.  page  445.)  The  supposed 
sanitary  significance  of  plumbing  inspection  was  inspired 
by  the  now  destroyed  sewer  gas  bogey.  We  now  know 
that  the  subject  is  one  affecting  comfort  rather  than 
health.  Plumbing  inspection  involves  the  application  of 
a  code  of  detailed  trade  rules  regulating  construction, 
and  should  properly  be  administered  by  the  building  or 
sewer  department.^ 

^  For  treatment  of  construction  see  Gerhard,  "  House  Drainage  and 
Sanitary  Plumbing,"  Van  Nostrand  Co.,  and  Gerhard,  "The  Water 
Supply,  Sewerage  and  Plumbing  of  Modern  City  Buildings,"  John  Wiley 
and  Sons,  Inc. 


ITOUSTNC.    AND   TNDUSTRTAF.    HYGIENE  423 

Types  of  Dwellings.  —  The  following  are  the  general 
types  concerned  in  the  housing  proljlem  as  related  to 
private  dwellings. 

1.  One-family  Dwellings. — The  promotion  of  this 
type  of  house  is  one  of  the  main  objects  of  housing  reform. 
Such  houses  may  be  built  detached,  each  with  its  own 
plot  of  ground;  suitable  inexpensive  houses  may  also  be 
built  in  blocks,  with  ground  in  front  and  rear.  In  the  city 
of  Philadelphia  such  dwellings  have  been  developed  with 
remarkable  success. 

2.  Two-family  Dwellings.  —  Dwellings  of  this  class 
may  also  be  very  satisfactory,  especially  when  the  land- 
lord lives  in  one  part  of  the  house.  There  are  two  types  in 
this  class:  (i)  the  double  house  with  a  party  wall  in  the 
middle,  with  separate  entrances  on  each  side  and  each 
family  having  one-half  the  house  throughout  the  entire 
building,  and  (2)  that  in  which  one  family  has  the  ground 
floor  and  possibly  the  basement,  and  a  second  family  has 
the  second  floor,  or  sometimes  the  second  and  third  floors, 
with  separate  entrances  for  each  family.  From  a  sanitary 
standpoint  such  dwellings  may  be  quite  as  satisfactory  as 
one-family  houses. 

3.  Tenements.  —  Here  we  class  (though  there  are  vari- 
ous definitions  of  tenement  houses  under  various  local 
laws)  houses  in  which  more  than  two  families  dwell  inde- 
pendently but  sharing  common  hallways.  It  is  against 
this  class  that  most  of  the  housing  reform  effort  has  been 
directed.  One  authority  (Veiller)  states  that  "the  tene- 
ment is  neither  necessary  nor  desirable."  Nevertheless  the 
tenement  is  a  result  of  economic  conditions  which  urge 
the  economy  of  land;  there  are  many  thousands  of  tene- 
ments in  existence  and  some  will  doubtless  continue  to  be 
built.  Health  and  housing  authorities  should,  however, 
place  strict  regulation  upon  their  construction  and  care, 
and  the  erection  of  new  tenements  (even  the  so-called 
"model   tenements")    should  be  strongly   discouraged  in 


424  A   MANUAL   FOR   HEALTH   OFFICERS 

those  places  (such  as  small  cities)  where  there  is  little  or 
no  economic  excuse  for  their  existence.  Even  in  the  larger 
cities,  with  the  extension  and  cheapening  of  rapid  transit 
it  is  to  be  hoped  that  suburban  dwelling  may  be  so  de- 
veloped as  to  do  away  in  a  large  degree  with  the  demand 
for  tenements.  We  need  not  here  discuss  the  various 
schemes  for  housing  in  "garden  cities"  and  the  like  which 
have  been  proposed;  these,  while  admirable,  belong  in  the 
realms  of  private  enterprise  and  philanthropy  and  not  in 
that  of  public  administration. 

The  housing  problem  is  not,  however,  limited  to  tenements. 
Very  frequently  conditions  found  in  houses  technically  of 
the  one-  or  two-family  class  are  quite  as  bad  as  those  in 
tenements.  The  health  officers  of  small  towns  and  cities 
will  find  this  often  to  be  the  case,  so  that  even  where  there 
are  no  tenements  whatever  serious  housing  problems  may 
exist.  Housing  codes  should,  therefore,  deal  with  small 
houses  as  well  as  multiple  dwellings.  Sometimes  improper 
construction  or  care  by  the  landlord  will  be  found;  also 
frequently  (especially  in  rapidly  growing  industrial  com- 
munities) the  crowding  of  more  than  one  family  into  a 
"one-family"  house,  and  of  more  than  two  families  into 
a  "two-family"  house.  Again,  the  lodger  evil  is  to  be  met 
with  in  all  types  of  dwellings.  The  overcrowding  of  pri- 
vate families  by  the  taking  in  of  lodgers  is  frequent  in 
industrial  communities,  especially  among  the  more  igno- 
rant immigrants.^ 

A  distinction  in  all  housing  regulations  should  be 
drawn  between  old  and  7ieiv  buildings.  It  is  clear  that 
while  old  buildings  may  be  altered  only  with  consider- 
able expense  and  difficulty,  strict  regulation  may  readily 
be  applied  in  the  construction  of  the  new.  In  the  for- 
mer case  regulation  is  remedial  and  comparatively 
limited,  while  in  the  latter  it  is  preventive  and  of  a  wide 
scope. 

'  See  reference,  p.  421. 


HOUSING    ANF)    TNDUSTRFAI,    UYCAKNK  425 

Public  Buildings. — The  principal  points  rcfiuirin^  at- 
tention in  public  and  seniipublic  Iniildings  —  such  as 
schools,  churches,  factories  and  workshops,  theatres  and 
moving  picture  shows,  public  baths,  court  houses  and 
other  municipal  and  state  buildings  —  are  cleanliness, 
lighting  and  ventilation.  The  last-mentioned  factor 
requires  the  most  attention  of  all,  for  in  the  buildings  of 
this  class  proper  ventilation  is  the  exce[)tion  ratlier  than 
the  rule.  Yet,  since  vast  numbers  of  people  spend  many 
hours  of  their  time  in  such  places  there  is  here  a  distinctly 
important  field  for  public  health  work. 

In  such  buildings  artificial  ventilation  systems  play  a  prime 
part.  The  installation  of  such  systems  is  the  work  of  ex- 
pert sanitary  and  mechanical  engineers  and  architects,  but 
it  is  the  duty  of  health  authorities  to  make  inspections  and 
tests  of  air  (see  below),  to  require  the  installation  of  systems 
where  necessary  and  to  insure  their  adequate  operation. 
The  failure  of  some  ventilating  systems  in  the  past  is  not 
(as  some  have  thought)  an  argument  for  returning  to 
"natural"  ventilation,  but  simply  for  more  expert  con- 
struction and  operation. 

Ventilation.  —  The  chief  requirements  of  present  venti- 
lating science  are  cleanliness  of  air  supply,  gentle  motion, 
and  temperature  and  humidity  adjusted  to  the  ordinary 
exercise  of  the  occupants.  Considerations  of  these  kinds 
have  taken  the  place  of  the  formerly  all-important  chemical 
ratios  of  oxygen  and  carbonic  acid,  w^iich  are  used  now 
simply  as  indicators  of  the  vital  conditions.  The  cleansing 
of  air  supplies  of  dust  and  other  impurities  by  mechanical 
and  chemical  methods  is  an  important  innovation,  for  the 
outside  air  of  modern  communities  is  frequently  heavily 
laden  with  such  impurities;  and  the  partial  re-circulating 
of  artificially  cleansed  inside  air  even  is  practiced.  At  the 
same  time,  while  present  emphasis  is  placed  on  the  physical 
factors,  the  important  question  of  the  chemical  freshness 
of  air  as  affected  by  minute  quantities  of  certain  volatile 


426  A  MANUAL  FOR  HEALTH  OFFICERS 

substances  present  has  not  yet  been  cleared  up.  The  sub- 
jects of  ventilation  and  ventilating  engineering  are  now 
developing  very  rapidly,  and  the  health  officer  should  be 
familiar  with  the  latest  developments.^ 

The  first  health  department,  so  far  as  the  writer  knows, 
to  take  up  the  systematic  supervision  of  the  ventilation  of 
public  buildings  was  that  of  Chicago,  which  in  1912  estab- 
lished a  Division  of  Ventilation.  Physical  and  chemical 
tests  are  made  in  workshops,  stores,  theatres,  street  cars 
and  other  places.  A  minimum  quantity  of  air  supply 
is  required  for  each  class  of  place.  The  regulations, 
methods,  instruments  and  forms  adopted  in  Chicago  will 
well  repay  the  study  of  health  departments  taking  up  this 
class  of  work.-  The  Chicago  requirements  (191 1)  for  air- 
renewal  range  from  1200  to  2000  cubic  feet  per  hour  per 
person,  according  to  the  class  of  establishment;  there  are 
also  requirements  as  to  air  space,  source  of  air  supply, 
drafts,  etc.  Thorough  work  requires  the  scientific  use  of 
psychrometers,  thermometers  and  other  instruments,  and 

1  See  Rosenau,  "Preventive  Medicine  and  Hygiene,"  1913,  sec.  IV; 
Kimball,  "Present  Status  of  Ventilation,"  Trans.  XV Internal.  Congress 
Hyg.  and  Demogr.,  vol.  IV,  part  II,  p.  547;  Winslow,  "The  New  Art 
of  Ventilation:  Some  Principles  which  Follow  from  Recent  Physiologi- 
cal Research,"  ibid.,  p.  560;  Winslow,  "School  Ventilation  in  New 
York  City,"  Am.  Jour.  Pub.  Ileallh,  1913,  vol.  Ill,  no.  11,  p.  1158; 
Phelps,  "Some  Fundamental  Physical  Factors  in  the  Problem  of  the 
Control  of  the  Atmospheric  Environment,"  ibid.,  p.  1123;  Bass,  "An 
Experiment  with  Ozone  in  School  Ventilation,"  ibid.,  p.  1135;  Eager, 
"Indoor  Tropics:  The  Injurious  Effect  of  Overheated  Dwellings, 
Schools,  etc.,"  Suppl.  no.  2  to  the  U.  S.  Pub.  Health  Rpts.,  Jan.  31,  1913. 
The  N.  Y.  Assn.  for  Improving  the  Condition  of  the  Poor  received  in 
1913  a  large  bequest  for  investigation  of  the  problem  of  ventilation; 
the  work  of  the  New  York  State  Commission  on  Ventilation  appointed 
at  its  request  is  to  be  viewed  with  much  interest.  Among  books  may 
be  consulted  Macfie,  "  Air  and  Health."  For  laboratory  work  on  air 
see  Appendix  D  of  the  present  work. 

^  Described  in  a  series  of  articles  by  Dr.  E.  Vernon  Hill  in  the  Metal 
Worker,  Plumber  and  Steam  Fitter,  Oct.  4  and  18,  Nov.  8  and  22,  and 
Dec.  6,  1912. 


HOUSrNCl    AND    INDUSTF-JIAf.    FfYCfKNK  427 

proper  reguUitiou  rc(iuirL's  temperature  ancl  humidity  stand- 
ards even  more  than  mere  sjiacc  and  air-supi)Iy  recjuire- 
ments. 

Air  Poisoning  by  Illuminating  Gas. —  Recent  scientific 
investigation  set  forth  in  an  imjoortant  pa[)er  by  Sedgwick 
and  Schneider'^  lias  demonstrated  the  dangerous  properties 
of  illuminating  gas  in  indoor  air,  even  when  existing  in 
very  small  quantities.  These  authors  preface  their  [)apcr 
with  the  following  observations: 

Sooner  or  later  students  of  infectious  diseases  must  give  closer  atten- 
tion than  they  have  yet  found  time  to  give  to  those  environmental  con- 
ditions which  increase  or  diminish  susceptibility  to  the  various  infections. 
When  they  do  this,  it  will  probably  be  found  that  obscure  poisonings  of 
various  kinds  play  a  large  part  in  diminishing  vital  resistance  and  in 
increasing  susceptibility.  The  facts  presented  in  the  present  paper  may 
be  taken  as  a  contribution  to  this  end,  for  they  show  how  in  urban  com- 
munities one  of  the  commonest  of  public  supplies  —  the  ordinary  gas 
supply  —  is  to-day  a  constant  menace  to  the  public  health,  attended  as 
it  is  not  only  by  numerous  fatalities  but  also  by  many  non-fatal  poison- 
ings which  signify  widespread  atmospheric  impurity  in  urban  dwellings. 
...  But  the  reader  must  not  suppose  that  [fatalities]  alone  are  of 
importance.  Probably  even  more  important  are  various  obscure  con- 
sequences of  the  leakage  of  illuminating  gas  in  pri's^ate  dwellings,  in 
public  halls  and  in  public  streets,  which  are  as  yet  seldom  thought  of 
and  even  more  seldom  detected. 

After  statistical  studies,  mainly  of  twelve  hundred  odd 
deaths  from  illuminating  gas  poisoning  in  Massachusetts 
in  the  preceding  twenty  years,  the  authors  discuss  the  com- 
position of  commercial  illuminating  gas  and  conclude  that 
an  increased  danger  was  introduced  with  the  increase  in 
the  proportion  of  the  more  dangerous  modern  water-gas 
as  compared  with  the  old-fashioned  coal-gas.- 

Through  the  above  study  two  lines  of  public  health  con- 

^  Sedgwick  and  Schneider,  "On  the  Relation  of  Illuminating  Gas  to 
Public  Health,"  Jour.  Inf.  Diseases,  191 1,  vol.  IX,  no.  3,  p.  380. 

-  The  approximate  proportion  of  the  dangerous  constituent,  car- 
bonic oxide,  in  coal-gas  is  7  per  cent,  in  water-gas  30  per  cent. 


428  A   MANUAL   I'OR   HIOALTH  OFFICERS 

trol  are  indicated:  lirst,  limitation  by  law  of  the  percent- 
age of  the  dangerous  clement,  carbonic  oxide  ;^  second, 
measures  to  prevent  the  leakage  of  gas  in  streets  and 
houses.  The  former  should  be  urged  upon  state  legisla- 
tures; the  latter  should  be  attended  to  by  local  authorities 
through  gas  inspections,  which  require: 

1.  Standards  for  the  construction  of  gas  fixtures  (so  as  to 
eliminate  cheap  and  fault>'  fixtures),  and  supervision  of  the 
installation  of  gas  piping  and  fixtures. 

2.  Regular  inspections  of  piping  and  fixtures  in  tenements 
(perhaps  to  some  extent  in  one-  and  two-family  houses) 
and  public  buildings  to  locate  leaks  and  cause  them  to  be 
repaired.  Attention  should  be  paid  to  possible  leaks  in 
entering  mains  underneath  houses,  from  which  gas  may 
rise  and  permeate  the  house  air.  Tenants  become  used 
to  the  atmospheric  conditions  in  their  houses  and  practically 
never  investigate  the  sources  of  gas  odors  or  think  them 
dangerous  to  health.  Such  inspections  require  no  ap- 
paratus beyond  a  reasonably  keen  sense  of  smell  (which  is 
readily  cultivated)  on  the  part  of  the  inspector.  Simple 
inspection  blanks  may  be  used,  together  with  red  tags 
bearing  some  such  phrase  as  ' '  Defective  —  Not  to  be  re- 
moved except  by  an  officer  of  the  board  of  health,"  to  be 
attached  to  leaky  pipes  and  fixtures  on  the  first  inspection 
and  not  to  be  removed  until  the  owner,  in  response  to 
notification,  has  remedied  the  defects  and  a  re-inspection 
has  resulted  in  approval. 

Inspection  of  new  installations  prevents  careless  work 
and  the  use  of  defective  piping  and  fixtures.  Appropriate 
pressure  tests  may  be  applied.  In  the  inspection  of  old 
systems  it  will  be  found  that  many  of  the  cocks  of  jets  and 
other  domestic  fixtures  become  loose  and  leaky  through  the 
drying-out  of  the  lubricating  grease. 

'  The  authors  urge  the  former  lo  per  cent  limit  of  Massachusetts, 
which  would  mean  that  the  percentage  of  water-gas  allowable  in  any 
mixture  would  be  strictly  limited. 


HOUSING   AND    FNDIJSTRIAI.    irVGIENR  429 

Such  supervision  of  new  and  inspection  of  oKl  installa- 
tions may  readily  he  carried  on  hy  the  officials  rcsponsihle 
for  plunihing  inspection.  It  is  a  duty  of  the  local  health 
authorities  either  to  institute  this  branch  of  activity  them- 
selves or  to  urge  its  adoption  upon  the  authorities  resjjon- 
sible  for  plumbing  inspection.  This  is  all  the  more 
necessary  now  that  water-gas,  which  has  little  warning 
odor  as  compared  with  coal-gas,  is  extensively  supplied, 
and  it  may  be  difficult  to  secure  legislative  restriction  of 
its  use.  A  number  of  health  departments  regulate  new 
installations,  but  the  inspection  of  old  installations  is 
unfortunately  as  yet  uncommon. "^  The  strict  regulation 
which  in  the  past  has  been,  and  still  is,  exercised  against 
the  escape  of  sewer  gas,  which  we  at  the  present  time 
know  to  be  innocuous  or  nearly  so,  should  now  be  turned 
to  the  vastly  more  important  problem  of  illuminating 
gas. 

Publicity  as  to  the  deleterious  effects  of  leaking  gas  in 
dwellings  and  the  desirability  of  thorough  ventilation,  par- 
ticularly at  night,  is  obviously  advisable. 

How  TO  Attack  the  Housing  Problem.  —  It  is  a  mis- 
take to  suppose  that  housing  problems  are  limited  to  the 
slums  of  large  cities.  Even  in  small  towns,  particularly  if 
they  be  rapidly  growing  industrial  communities,  the  typical 
evils  appear  in  run-down  or  overcrowded  houses  of  ordinary 
types,  while  if  tenements  of  improper  types  have  begun  to 
appear  the  situation  demands  all  the  more  attention.  In 
taking  up  the  problem  health  authorities  must,  however, 
remember  that  important  factors  other  than  sanitation  are 
concerned,  and  frequently  they  will  find  the  cooperation 
of  private  organizations  very  useful.  Housing  campaigns 
are  perhaps  usually  initiated  by  such  organizations. 

1  This  important  class  of  inspections  may  readily,  and  should,  be 
taken  up  by  the  plumbing  inspector,  especially  during  those  months 
when  there  is  a  minimum  of  plumbing  inspection.  Such  a  plan  was 
instituted  under  the  supervision  of  the  writer  at  Orange,  N.  J. 


430  A   MANUAL    FOR    HI'.ALTII   OFFICERS 

The  following  steps  arc  necessary  in  a  campaign  for 
housing  reform:  ^ 

1.  A  Survey  of  the  Conditions.  —  This  should  properly  be 
carried  out  by  the  constituted  health  authorities,  or  at 
least,  when  it  is  necessary  to  rely  on  private  societies  for 
funds  to  carry  out  the  investigation,  with  official  cooper- 
ation. Such  a  survey  need  not  be  exhaustive,  but  should 
be  sufficiently  tliorough  to  demonstrate  clearly  the  typical 
evils  which  exist,  their  approximate  extent  and  the  neces- 
sary remedies.  If  it  is  part  of  a  general  public  health  survey 
all  the  better.  Such  surveys  should  evidently  be  accurate 
and  built  up  on  a  backbone  of  statistical  findings,  and 
should  be  conducted  under  expert  direction,  which  it  may 
frequently  be  necessary  to  engage  for  the  occasion. 

2.  Publicity.  —  The  making  public  of  the  findings  pre- 
pares the  ground  for  obtaining  necessary  legislation  and 
increased  health  appropriations. 

3.  Legislation.  —  Revised  legislation  is  usually  necessary. 
It  should  be  adopted  in  accordance  with  local  needs,  con- 
sidering the  future  as  well  as  the  present,   and   the  best 
present-day  practice- 
Distinction  must,  however,  be  made  between  regulations 

which  have  for  their  object  safety  and  decency,  dealing 
with  construction,  water  pressure,  fire  risks,  etc.,  and  those 
relating  directly  to  public  health.  The  former  are  properly 
the  business  of  the  municipal  building  inspector  or  de- 
partment of  building  inspection;  the  latter  only  of  the 
health  department.  Since  everything  not  relating  directly 
to  health  should  be  assigned  to  the  building  department, 
leaving  the  health  department  to  deal  intensively  with  its 
own  problems,  it  is  not  practicable  to  combine  all  housing 
regulations  in  a  single  "code."     Those  portions  of  such  a 

^  See  Veiller,  "A  Housing  Programme,"  Nat.  Housing  Assn.  Publi- 
cations no.  16. 

2  See  Veiller,  "A  Model  Housing  Law"  (Sage  Foundation  Publica- 
tion), Survey  Associates,  Inc.,  105  East  22nd  St.  N.  Y.  City,  1914,  $2. 


HOUSINf;   ANF)   TNDlJSTRrAr.    iWCfKNF.  43^ 

theoretical  code  which  bear  specifically  on  hcallii  sliould 
therefore  be  incori)oraLed  in  the  ordinances  of  the  Ijoard  of 
health,  and  the  division  of  responsibility  between  building 
inspection  and  health  departments  should  be  clearly  de- 
fined. Otherwise  those  duties  which  are  ambiguous  will 
fall  into  either  conllict  of  authority  or  neglect.  ICvery  set 
of  health  regulations  should  contain  a  mininnini  oi  re- 
([uirements  covering  the  ground  which  we  have  already 
sketched,  e.g.,  the  subjects  of  light  and  ventilation,  cleanli- 
ness, avoidance  of  overcrowding,  lodgers,  water  for  do- 
mestic purposes,  convenient  and  proper  plumbing,  safe  gas 
piping  and  fixtures,  and  the  like. 

4.  Enforcement. — The  general  enforcement  of  regulations 
relating  to  houses  can  only  be  accomplished  by  means  of  reg- 
ular house-to-house  inspections.  In  these  the  object  should 
be  to  make  a  brief  but  thorough  survey  of  each  house  and 
premises,  the  inspections  being  made  not  less  often  than 
once  a  year.  Merely  waiting  for  complaints  will  produce 
practically  no  results.  Such  inspections  should  cover 
the  building,  plumbing  (and  gas  piping  and  fixtures  un- 
less otherwise  provided  for  —  see  remarks  in  a  preceding 
section),  and  out-premises.  Ordinary  nuisances  should  be 
looked  for,  including  fly  and  mosquito  breeding,  unless  there 
are  special  inspections  for  these  purposes.  The  records 
kept  should  be  of  the  simplest  description,  consisting  simply 
of  a  list  of  points  for  the  inspector  to  check  off  and  brief 
forms  for  entering  reports  of  objectionable  conditions 
found.  The  mistake  is  sometimes  made  of  making  these 
house-to-house  records  so  detailed  that  a  great  deal  of 
time  is  wasted  in  filling  them  in  with  information  which 
is  of  little  or  no  subsequent  use.  The  proposal  has  been 
made  that  house-to-house  inspection  be  made  by  women 
inspectors,  who  might  combine  some  sanitary  instruction 
with  their  inspectorial  functions,  and  this  is  worthy  of  con- 
sideration. It  is  work  which  might  well  be  done  b^'  women 
and  would  be  of  special  value  in  those  frequently  occurring 


432  A   MANUAL   FOR   HEALTH   OFFICERS 

instances  where  the  blame  for  unsanitary  conditions  lies 
with  the  habits  of  life  of  the  tenants  and  the  difficulty  can 
only  be  permanently  remedied  through  education. 

In  some  of  the  states  the  responsibility  for  the  super- 
vision of  tenements  rests  with  a  special  state  tenement 
inspection  department.  While  this  is  very  desirable  where 
there  are  large  numbers  of  such  dwellings,  their  existence 
does  not  relieve  local  health  authorities  of  the  responsibility 
of  cooperation  and  of  attending  to  many  of  the  minor 
conditions  which  can  so  much  more  readily  be  attended  to 
by  the  local  inspectors  constantly  on  the  spot  than  by 
those  from  the  tenement  department,  who  may  visit  the 
town  only  at  considerable  intervals.  This  remark  applies 
especially  to  a  large  class  of  minor  complaints  and  nuisances 
which  frequently  arise  on  tenement  premises.  It  is  im- 
proper, therefore,  for  local  officers  to  omit  inspections  of 
tenements  simply  because  a  tenement  department  has  more 
extensive  powers  therein;  these  latter  are  to  be  resorted  to 
only  in  the  more  difficult  and  special  cases.  It  must  be 
remembered  also  that  the  powers  of  tenement  bureaus  do 
not  usually  extend  to  dwellings  housing  fewer  than  three 
families  (consult  local  state  laws  for  definition  of  powers). 
In  order  to  assist  in  the  administration  of  the  tenement  laws 
it  would  be  wise,  wherever  legally  feasible,  to  pass  an  ordi- 
nance incorporating  (by  title)  the  state  tenement  house 
law  into  the  ordinances  of  the  local  board  of  health  in  so 
far  as  it  relates  to  light,  air  space,  sleeping  quarters,  dirt 
and  filth,  storage  of  refuse,  sewer  connections,  plumbing, 
cesspools,  and  privies,  and  providing  a  local  penalty  for 
violations.  This  also  furthers  a  desirable  consistency  be- 
tween state  and  local  requirements. 

The  enforcement  of  sanitary  housing  regulations  in- 
volves relationships  between  health  officer,  landlords, 
tenants  and  janitors,  the  management  of  which  requires 
justice  and  tact.  Care  should  be  taken  to  fix  responsibility 
as  exactly  as  possible,  for  injustice  in  this  regard  destroys 


HOUSIN(;    AND    INfDUS'lRfAL    MYGIKNE  433 

respect  for  the  authorities  and  leads  to  bad  feeling  among 
the  various  parties,  leading  to  defeat  of  the  law.  Land- 
lords are  as  a  rule  ready  to  comfjly  with  just  and  reasonable 
orders  (even  though  involving  considerable  expenditures) 
if  they  are  convinced  of  the  necessity  and  arc  satisfied  that 
the  law  is  also  being  impartially  administered  in  respect  to 
other  landlords.  Very  frequently,  however,  tenants  are  at 
fault  but  believe  that  the  authorities  will  place  the  re- 
sponsibility on  the  landlord;  the  health  officer  should  not 
be  misled  by  this  attitude  but  should  proceed  vigorously 
against  the  tenant.  Sometimes  the  fault  lies  with  ignorant 
or  careless  janitors.  The  importance  of  the  functions  of 
the  janitor  are  not  sufficiently  recognized;  in  schools  and 
other  institutions  they  play  a  prominent  part,^  and  in 
tenements  greater  care  in  their  selection  on  the  part  of 
landlords  would  result  in  saving  trouble,  money  and  public 
health  and  convenience.  Another  factor  in  regard  to 
housing  supervision  is  the  police,  who  not  infrequently  meet 
with  conditions  which  should  be  referred  to  the  health 
department  (see  page  446). 

CONCLUSION 

Little  has  been  done  by  health  officials  in  this  country 
to  approach  the  housing  problem  in  its  deeper  conditions. 
The  reason  for  this  is  clear.  Public  health  is  only  one 
aspect  of  a  large  problem  which  must  be  attacked  coopera- 
tively from  several  directions.  Safety,  economy,  morality 
make  it  a  sociological  problem  as  well  as  a  merely  sani- 
tary one.  In  dealing  with  it  from  the  sanitary  point  of 
view  we  find  that  results  are  indefinite,  slow  and  that  the 
factor  of  personal  hygiene  is  so  great  that  education  must 
play  a  large  part.  For  such  reasons  health  officers  must 
frequently  have  felt  that  limited  funds  and  efforts  could 
and  should  be  expended  in  ways  which  would  bring  more 
immediate  and  demonstrable  results.  Nevertheless,  hous- 
^  See  Putnam,  "School  Janitors  and  Health,"  1913. 


434  A  MANUAL   FOR    1  HEALTH   OFFICERS 

iiig  will  always  remain  one  of  the  i)riine  inlluences  on  health, 
to  which  every  health  department  should  pay  as  much 
attention  as  is  consistent  with  its  other  duties.  There 
is,  perhaps,  no  other  field  in  which  preventive  measures 
should  look  so  far  ahead,  and  should  so  anticipate  the  evils 
of  growing  communities.  Such  evils  are  far  more  easily 
prevented  than  cured.  In  such  efforts  it  should,  so  far  as 
practicable,  cooperate  with  the  local  building  department, 
local  and  state  housing  organizations  and  departments, 
and  other  organizations  working  toward  similar  ends. 

REFERENCES 

Annual  Proceedings  of  the  National  Housing  Association,  105  East 
22nd  St.,  New  York  City. 

Vciller,  "Housing  Reform,"  National  Housing  Association,  1910. 

De  Forest  and  Veiller  (Editors),  "The  Tenement  House  Problem," 
National  Housing  Association,  1903. 

INDUSTRIAL  HYGIENE 

The  hygiene  of  occupations  is  manifestly  of  the  greatest 
importance  to  the  public  health,  ranging  as  it  does  from 
the  simplest  work  done  in  the  home  through  all  the  various 
kinds  of  workshops,  stores,  offtces,  etc.,  to  the  complex  in- 
dustrial organization  of  great  factories.  Our  treatment  of 
the  subject  here  must  necessarily  be  of  the  most  general 
character,  for  industrial  hygiene  is  a  vast  separate  depart- 
ment of  sanitary  science  and  art,  the  details  of  which  cannot 
be  treated  in  a  cursory  manner.  Moreover,  the  problems 
of  each  community  present  individual  characteristics  de- 
pending upon  the  local  industries.  The  latter  and  their 
effects  on  the  public  health  should  be  the  subject  of  special 
study  by  the  health  officer  of  each  community  possessing 
any  industrial  population.  A  distinction  should  also  be 
made  between  those  factors  pertaining  to  personal  hygiene 
and  which  are  best  dealt  with  by  education  in  personal 
hygiene,  and  those  of  a  public  nature  which  may  be  con- 
trolled by  public  authorities. 


HOUSING   ANT)   INDUSTRIAL  HYGIENE  435 

Factors.  —  The  problems  involved  in  industrial  hygiene 
relate  to  hours  of  Ia])or,  to  fatigue  under  various  ccjnditions, 
to  the  labor  of  cliildren,  to  the  labor  of  women  as  it  affeets 
both  them  and  their  offspring.  In  factories  and  workshops 
(as  in  dwellings)  are  met  problems  of  ventilation  and  of 
detrimental  substances  (dust,  fumes,  etc.)  in  the  air,  of 
cleanliness  and  decency,  and  of  transmission  of  infection 
(as  by  spitting).  Of  a  more  special  nature  there  is  a  great 
class  of  problems  relating  to  diseases  of  occupation,  each  in- 
dustry exerting  its  own  particular  deleterious  influences  on 
health  which  are  to  be  counteracted.  In  addition  to  the 
sanitary  considerations  there  are  questions  of  safety,  of 
efficiency,  and  of  social  well-being  which  are  connected  more 
or  less  directly  with  those  of  health.  No  community  can 
afford  to  neglect  the  problem  of  industrial  hygiene,  for 
even  where  no  factor!^,  properly  speaking,  exist,  there  are 
always  such  establishments  as  bakeries  and  other  places 
where  food  is  prepared,  laundries,  etc.,  in  which  the  health 
of  the  workers  is  an  important  consideration.  We  have 
already  referred  in  a  previous  chapter  to  the  sanitation  of 
food  establishments;  there,  however,  having  the  purity  of 
the  products  in  mind,  while  here  the  question  relates  to 
the  workers. 

Control.  —  While  the  whole  problem  of  industrial  hy- 
giene is  usually  not  to  be  attacked  single-handed  by  the 
local  health  authorities,  there  are  certain  regulations 
which  they  can  and  should  make  and  enforce,  especially 
where  no  special  system  of  factory  inspection  exists.  Such 
regulations  would  cover  ventilation  (see  preceding  pages) 
and  deleterious  substances  in  the  atmosphere.  Proper 
artificial  ventilating  systems  might  well  be  required  in  in- 
stances where  natural  ventilation  is  not  sufficient  to  keep 
the  temperature  and  humidity  down  to  a  proper  standard 
and  the  air  reasonably  free  from  injurious  constituents. 
Cleanliness  should  be  required.  Promiscuous  spitting  in 
workshops  should  be  forbidden  and  proper  receptacles  for 


436  A  MANUAL   FOR  HEALTH  OFFICERS 

sputum,  such  as  to  obviate  possible  infection,  should  be 
required  where  necessary.  Cleanliness  and  decency  in 
water-closet  arrangements  should  be  insisted  upon,  to- 
gether with  the  provision  of  proper  lavatory  facilities. 
Such  regulations  should  be  enforced  through  sufficiently 
frequent  inspections. 

Some  hygienic  instruction  of  the  workers,  especially  in 
the  hygiene  of  their  particular  trade,  is  of  great  value,  for, 
as  Oliver  remarks,  "no  matter  what  .  .  .  legislation  may 
enact,  industrial  hygiene  will  never  be  secured  until  the 
workers  themselves  are  educated  in  regard  to  the  dangers 
incidental  to  particular  trades  and  are  willing  to  cooperate 
in  making  .  .  .  regulations  effective."  Such  instruction 
may  consist  in  talks  delivered  in  cooperation  with  trades 
organizations. 

The  medical  examination  of  workers,  e.g.,  for  tuber- 
culosis and  other  conditions,  is  an  important  movement. 
Factory  inspection  authorities  or  employers  have  taken  this 
up  in  certain  instances. 

Other  sweeping  matters  are  usually,  as  they  should  be, 
dealt  with  by  statutory  legislation  administered  by  stale 
factory  inspection  bureaus:  questions  of  hours  and  methods 
of  labor,  of  child  and  female  labor,  of  the  special  measures 
to  be  adopted  for  safety  and  for  prevention  of  diseases  of 
occupation.^  In  several  states,  following  the  excellent 
example  of  Wisconsin,  the  reporting  of  industrial  diseases 
by  physicians  is  required.     Among  the  more  common  occu- 

^  Such  diseases  are  classified  by  Oliver  as  follows:  —  (i)  due  to  gases, 
vapors,  and  high  temperatures;  (2)  due  to  conditions  of  atmospheric 
pressure;  (3)  due  to  metallic  poisons,  dusts  and  fumes;  (4)  due  to 
organic  or  inorganic  dust  and  heated  atmospheres;  (5)  due  to  fatigue. 
To  these  conditions  might  be  added  lighting  and  optics  in  relation  to 
eye-strain  and  nervous  disorders,  to  which  considerable  attention  is  now 
being  paid.  Other  causes  of  nervous  strain,  e.g.,  unnecessary  noise,  etc., 
should  also  be  considered.  Such  classifications  as  the  above  are,  of 
course,  arbitrary;  each  occupation  requires  individual  study  and  special 
measures  of  control. 


HOUSING   AND    INDUSTRIAf.    FfYGIf-lNP:  437 

pational  diseases  may  be  mentioned:  poisoniiij^  by  lead, 
phosphorus,  arsenie,  mercury  and  brass;  caisson  disease; 
and  parasitic  diseases,  as  anthrax  ("  wcn^l-sorter's  cHsease") 
and  hooic-worm  (miners).  The  relation  of  chjsty  trades  and 
other  depressant  industrial  conditions  to  tuberculosis  is  a 
highly  important  problem  (cf.  page  160  f.). 

The  statistics  of  industrial  disease  form  an  important 
special  branch  of  vital  statistics.  In  dealing  with  such 
figures  particular  caution  must  be  exercised  on  account  of 
the  many  factors  involved  and  the  consequent  liability  to 
misleading  results. 

With  increasing  effectiveness,  the  country  over,  matters 
of  industrial  hygiene  are  being  dealt  with  by  legislatures, 
by  specially  established  state  factory  inspection  bureaus,  by 
employers,  and  by  employees'  organizations  such  as  the 
trades  unions.  A  cooperation  of  all  these  is  evidently  de- 
manded. Such  cooperation  sometimes  takes  an  official 
form,  as  in  the  Joint  Board  of  Sanitary  Control,  composed 
of  representatives  of  manufacturers,  employees  and  public, 
for  the  regulation  of  the  sanitation  of  the  cloak  and  suit  in- 
dustries of  greater  New  York.  The  American  Museum  of 
Safety  (29  West  39th  Street,  New  York  City)  acts  as  a 
center  for  the  dissemination  of  information  relating  to  in- 
dustrial safety  and  hygiene.  The  work  of  the  National 
Consumers'  League  and  the  American  Association  for  Labor 
Legislation  (publishing  American  Labor  Legislation  Review) 
also  demand  high  mention. 

REFERENCES 

Price,  "The  Modern  Factory:  Safety,  Sanitation  and  Welfare," 
John  Wiley  and  Sons,  Inc.,  New  York,  1914. 

Thompson,  "The  Occupational  Diseases:  Their  Causation,  Sj-mp- 
toms,  Treatment  and  Prevention,"  Appleton,  New  York,  1914. 

Hanson,  "  Hygiene  of  Occupation,"  in  Harrington's  "  Manual  of 
Practical  Hygiene,"  1914. 

Rosenau,  "Preventive  Medicine  and  Hygiene,"  1913,  sec.  X. 

Oliver,  "Diseases  of  Occupation,  from  the  Legislative,  Social,  and 


438  A  MANUAL   FOR  HEALTH  OFFICERS 

Medical  Points  of  View,"  New  York,  1909;  also  "Dangerous  Trades," 
by  the  same  author. 

Various  authors:  "Risks  in  Modern  Industry-,"  pub.  by  American 
Academy  of  Political  and  Social  Science,  Phila.,  1912. 

Andrews,  "Occupational  Diseases  and  Legislative  Remedies,"  Am. 
Jour.  Pub.  Health,  1914,  vol.  iv,  no.  3,  p.  179  (cf.  editorial  in  same  issue). 

Among  other  sources  of  information  not  alread\-  mentioned  are:  the 
transactions  of  the  International  Congresses  on  Hygiene  and  Demog- 
raphy (vol.  iii,  part  ii,  of  the  Transactions  of  the  XV  Congress)  and  of 
the  National  and  International  Congresses  on  Industrial  Hygiene;  re- 
ports of  the  various  state  factory  inspection  bureaus;  reports  of  English 
Parliamentary  Investigating  Committees;  etc. 

The  Americati  Jour7ial  of  Public  Health  publishes  a  department  on 
Industrial  Hygiene  and  Sanitation,  and  the  American  Public  Health 
Association  has  a  Committee  on  the  subject. 


CHAPTER    VI 
NUISANCES 

"A  nuisance,"  wrote  Blackstone  in  his  famous  Commen- 
taries on  the  law,  "signifies  anything  that  worketh  hurt, 
inconvenience,  or  damage."  To  this  it  may  be  added  that 
to  constitute  a  nuisance  in  the  legal  sense  there  must  be 
substantial  damage  resulting  from  an  unreasonable  use 
of  property  or  liberty.  "A  private  individual  may  not 
use  his  property  or  his  liberty  in  such  a  way  as  to  do  any 
substantial  damage  to  his  neighbors  or  to  the  whole  com- 
munity, and  he  must  conduct  his  business,  however  useful 
it  may  be,  in  a  way  that  is  reasonable."^  Just  what  is 
substantial  damage  and  what  constitutes  unreasonable  use 
under  given  circumstances  are  questions  for  proof  and 
judicial  decision  in  doubtful  cases,  for  the  class  of  nuisances 
has  no  hard  and  fast  boundaries.  Under  this  general 
definition  nuisances  at  law  constitute  a  large  class  of 
wrongs,  some  of  a  private,  some  of  a  public  nature.  Out  of 
that  large  class  we  are  here  limited  to  nuisances  of  a  public 
nature  which  affect  (or  are  presumed  by  tradition  or  the 
law  to  alTect)  health. 

Health  authorities  are  vested  with  very  general  powers 
over  nuisances  of  this  latter  group,  and  are  even  permitted 
to  define  what  shall  be  deemed  to  constitute  nuisances. 
Such  definitions,  however,  are  restricted  by  traditional 
ideas  as  recorded  in  common  law,  and  are  subject  to  review 

1  Wambaugh,  "  Nuisances,  Under  the  Law,"  A7n.  Jour.  Pub. 
Health,  1914,  vol.  IV,  no.  2,  p.  145.  The  standard  legal  work  on 
nuisances  is  Joyce,  "  Law  of  Nuisance,"  1906. 

439 


440  A    MANUAL   FOR    UKALTH   OFFICERS 

by  the  courts  to  determine  whether  they  are  in  accord  with 
those  ideas  in  instances  where  actual  detriment  to  health 
is  difficult  or  impossible  to  prove.  In  addition,  legislatures 
may  define  and  declare  specific  nuisances,  which  are  then 
before  the  law  ipso  facto  nuisances  beyond  debate.  In 
short,  health  authorities  have  power  to  deal  with  nuisances 
of  three  classes:  (/)  those  traditionally  accepted;  (2)  those 
which  they  can  prove  detrimeyital  to  health  luider  general 
pozvers  for  the  protection  of  public  health;  and  (j)  those 
specifically  defined  by  statute  law. 

The  first  class  includes,  among  others,  many  conditions, 
which,  according  to  modern  scientific  ideas,  are  of  little  or 
no  demonstrable  detriment  to  health,  but  which  frequently 
tend  toward  questions  of  comfort  or  decency.  These  have 
come  down  to  us  from  times  when  the  sources  of  disease 
and  the  conditions  affecting  health  were  less  fully  under- 
stood than  now.  Still  they  involve  considerations  of  clean- 
liness, proper  disposal  of  waste  matters,  and  the  like,  which 
are  of  importance  in  indirect  (and  sometimes  in  direct) 
health  protective  measures.  Under  the  second  class  might 
be  included  a  large  number  (in  fact  theoretically  all)  of  the 
conditions  affected  by  public  health  regulations;  this  class 
may  be  enlarged  as  far  as  injury  to  health  can  be  proved. 
Under  the  third  class,  legislatures  make  any  specific  defi- 
nitions required. 

The  heterogeneous  body  of  nuisances  dealt  with  by  health 
authorities  may  be  arranged  in  a  practical  manner  as 
follows: 

/.    Nuisances  involved  in  the  Disposal  of  Wastes: 

1.  Disposal  of  human  excreta. 

2.  Disposal  of  other  wastes   (garbage,   manure 

and  other  refuse). 
//.    Nuisances  due  to  Insects  and  Vermin: 

1.  Flics. 

2.  Mosquitoes. 

3.  Other  insects  and  vermin. 


NUISANCES  441 

///.    Miscellaneous  Nuisances:  ^ 

1.  Spitting. 

2.  Air  contamination   (smoke,   dust,   gases,   ob- 

noxious trades,  etc.). 

3.  Noise. 

Relation  of  Nuisances  to  Health.  —  So  mucii  of  the 
activity  of  health  authorities,  traditionally  and  at  the 
present  time,  is  concerned  with  nuisances  tliat  a  clear  idea 
of  proportion  must  be  preserved.  The  various  nuisances 
under  the  above  classification  should  be  given  very  different 
weights  in  the  sanitary  scale,  and  the  health  authorities 
should  consider  them  in  accordance  with  those  true  weights. 

Thus,  under  group  I,  the  disposal  of  excreta  and  sewage  is 
of  paramount  weight,  for  here  the  important  problem  of 
typhoid  fever  and  other  intestinal  diseases  is  vitally  con- 
cerned. The  disposal  of  all  other  kinds  of  waste,  from  gar- 
bage down  to  ordinary  dirt,  is  of  decidedly  secondary 
weight,  for  such  waste  influences  the  spread  of  disease  in 
only  a  very  indirect  manner. 

Under  group  II  the  question  of  the  propagation  of  disease 
is  of  greater  or  less  importance  according  to  circumstances. 
Where  flies  are  numerous  and  excreta  or  other  source  of 
infection  are  exposed,  particularly  in  warm  climates,  the 
suppression  of  flies  becomes  a  serious  consideration;  under 
other  circumstances  it  may  be  a  minor  matter.  Where 
malaria  and  yellow  fever  exist,  the  suppression  of  mosquito- 
breeding  is  a  first  duty  of  the  health  department;  other- 
wise it  is  rather  a  matter  of  public  comfort  and  property 
values.  Similar  consideration  applies  to  rats;  ordinarily 
they  produce  simply  a  problem  of  economic  destruction, 
but  when  plague  appears  they  become  almost  the  whole 
object  of  attack. 

The  nuisances  of  group  III  are  also  of  varying  impor- 

^  Any  thing,  condition  or  act  detrimental  to  health  in  addition  to 
those  mentioned  here  may  also  in  general  be  defined  as  a  nuisance,  e.g., 
polluted  water  supplies,  rooms  and  dwellings  unfit  for  occupancy,  etc. 


442  A  MANUAL   FOR   HEALTH   OFFICERS 

tance  according  to  circumstances.  The  role  of  the  public 
spitting  nuisance  in  the  spread  of  tuberculosis,  etc.,  ap- 
pears to  have  been  exaggerated,  relatively  to  more  direct 
modes;  but  when  promiscuous  spitting  is  frequent,  or  when 
it  takes  place  in  factories  and  workshops  and  under  other 
conditions  of  confinement,  it  becomes  a  clear  danger  to 
health.  Again,  air  pollution  is  of  greater  or  less  impor- 
tance according  to  its  degree  and  nature. 

The  conclusion  to  be  drawn  from  all  these  considerations 
is  that  health  authorities  should  pay  first  attention  to  those 
nuisances  which  are  actually  and  distinctly  (;Jetrimental  to 
health  rather  than  to  those  which  have  only  an  indirect 
connection  with  it  or  are  merely  the  subjects  of  a  mistaken 
popular  clamor.^ 

While  it  is  true  that  health  is  connected  with  questions 
of  comfort  and  decency,  and  that  general  measures  for 
cleanliness  and  a  wholesome  environment  are  a  part  of  the 
public  health  campaign,  nevertheless  it  is  the  duty  of 
modern  health  authorities  to  devote  the  bulk  of  their 
resources  —  always  limited  —  to  the  suppression  of  direct 
and  specific  causes  of  disease.  There  has  been  far  too  much 
vague  and  general  dealing  with  nuisances  without  discrimi- 
nation as  to  the  importance  of  some  and  the  non-importance 
of  others;  health  officials  should  abandon  this  outworn 
policy,  and  the  public  should  be  educated  to  respect  the 
more  scientific  attitude.  Non-sanitary  nuisances  will  be 
further  discussed  presently. 

Legal  Remedies  for  Nuisances.  —  Granted  that  evidence 
has  been  obtained  that  a  nuisance  exists,  health  authorities 
have,  in  general,  several  legal  weapons  at  their  disposal. 

I.  Suit  for  Penalty.  —  Every  local  board  of  health 
should  have  among  its  ordinances  sections,  passed  under 
the  general  authority  of  statute  law,  defining  the  various 

•  Probably  less  than  one-quarter  of  the  nuisances  in  sewered  commu- 
nities relate  directly  to  health.  The  true  sanitary  nuisances  are  chiefly 
those  connected  with  disposal  of  excreta. 


NUISANCES  443 

kinds  of  nuisances  suhjccl  to  sanitary  control  and  f)ro- 
viding  penalties  for  the  persons  resi)onsihle  for  maintaininf^ 
them.  The  commonest  and  altogether  the  most  effective 
method  of  dealing  with  a  nuisance  is  then  to  serve  a  notice 
on  the  responsible  person,  describing  the  nuisance  and 
ordering  its  abatement  either  forthwith  or  within  a  stated 
time.  (Such  notices  and  all  procedures  should  be  in  strict 
accordance  with  the  provisions  of  the  law.)  Even  if  such 
notice  may  not  be  explicitly  required  by  law,  it  is  customary 
and  reasonable  to  take  this  action  in  order  to  allow  the 
responsible  person  opportunity  to  abate  the  nuisance  in 
time  or  to  be  heard  by  the  health  authorities  so  that  he  may 
state  any  justification  which  he  may  wish  to  put  forward. 
If,  however,  the  order  is  not  complied  with  and  there  ap- 
pears to  be  no  reason  why  it  should  not  be,  then  legal  action 
may  be  started  for  collection  of  the  penalty  incurred. 
This  usually  results  in  the  abatement  of  the  nuisance, 
though  it  may  be  necessary  to  sue  repeatedly  for  penalties 
or  even  to  carry  an  appeal  to  higher  courts.  On  the  whole, 
the  method  of  suit  for  penalty  is  simple,  convenient  and 
brings  prompt  results. 

2.  Abatement  by  Health  Authorities.  —  The  law 
sometimes  provides  that  if  the  notification  of  the  health 
authorities  is  not  obeyed,  they  may  proceed  to  abate  the 
nuisance  themselves  and  charge  the  costs  on  the  property. 
This  method  is  applicable  in  instances  where  the  owner 
cannot  be  readily  reached  by  notice,  and  where  the 
nuisance  is  of  a  pressing  character.  It  is,  how^ever, 
little  employed  and  should  be  used  wnth  caution  for  the 
reasons  that  the  abatement  must  be  very  fully  justified  in 
the  eyes  of  the  law  and  that  the  collection  of  the  costs  is 
likely  to  prove  difficult. 

3.  Injunction.  —  Under  special  circumstances  applica- 
tion may  be  made  to  the  proper  court  for  an  injunction  to 
enjoin,  or  restrain,  a  person  or  corporation  from  committing 
or  maintaining,  or  continuing  to  commit  or  maintain,  a 


444  A  MANUAL   FOR  HEALTH  OFFICERS 

nuisance.  This  procedure  applies  especially  to  nuisances 
arising  from  factories  and  the  like,  where  ordinary  penalties 
are  inadequate  and  where  a  more  drastic  remedy  for  a 
serious  nuisance  is  desired.  It  has  the  advantage,  not 
possessed  by  the  other  methods,  of  forbidding  a  threatened 
nuisance  and  of  acting  as  a  weighty  check  over  longer 
periods  of  time.  It  is  likely,  however,  to  be  slow  and  costly 
and  to  involve  considerable  legal  question,  and  hence,  as 
already  remarked,  is  to  be  reserved  for  very  special  cases. 

Under  some  circumstances  it  may  be  advisable  to 
proceed  simultaneously  under  two  or  more  separate 
procedures. 

Private  Remedies.  —  Aside  from  the  powers  possessed 
by  public  health  authorities,  private  persons  have  certain 
important  remedies  against  nuisances  which  directly  affect 
them  as  individuals.  For  demonstrable  injury  to  property, 
a  suit  for  damages  may  be  instituted,  or  application  may 
be  made  for  an  injunction  to  abate  an  existent  nuisance 
or  to  prevent  a  threatened  one.  Where  annoyance  exists, 
though  no  injury  to  property,  a  grand  jury  indictment 
may  be  secured.  In  these  cases  it  is  to  be  noted  that 
injury  to  health  need  not  be  proved,  but  only  annoyance. 
Certain  nuisances  which  the  health  authorities  would  find 
it  very  difficult  or  impossible  to  deal  with  may  thus  be 
remedied  by  private  action.  This  applies  particularly  to 
classes  of  nuisances  (e.g.,  the  noise  nuisance)  over  which 
the  power  of  the  health  authorities  is  weak  or  nil.  Again, 
where  stream  pollution  is  in  question,  a  property  owner, 
by  invoking  the  law  of  riparian  rights,  may  secure  results 
which  public  authorities,  in  the  absence  of  explicit  statutory 
provision,  might  not  be  able  to  obtain  on  account  of  in- 
ability to  prove  a  public  nuisance. 

Further  than  the  above  sketch  of  remedies  we  cannot  go, 
on  account  of  the  difTerences  of  legal  procedure  prescribed 


NUISANCKS  445 

in  the  various  States,  and  the  legal  questions  involvcfl  in 
the  consideration  of  the  different  kinrls  of  nuisances. 

Administrative  Control  of  Nuisances  —  Non-Sanitaky* 
Nuisances.  —  It  has  already  been  pointed  out  that  the 
majority  of  nuisances  pertain  to  public  comfort  and  de- 
cency rather  than  to  public  health.  Such  are  those  which 
relate  to  the  disposal  of  garbage  and  ordinary  refuse  such 
as  old  rags  and  papers,  ashes  and  the  like.  Since  a  great 
deal  of  the  routine  attention  of  the  average  health  depart- 
ment —  following  tradition  —  is  spent  on  such  matters,  it 
would  be  desirable  to  have  them  referred  so  far  as  possible 
to  other  departments  of  the  municipal  government  which 
may  be  made  logically  and  directly  responsible  for  them. 
The  disposal  of  house  refuse,  dead  animals,  etc.,  is  a  matter 
of  municipal  engineering,  like  sewerage  and  street-cleaning, 
and  should  be  handled  by  a  special  department  of  the  local 
government.  The  inspection  of  plumbing  (cf.  page  422) 
might  well  be  handled  by  the  building  or  sewer  department. 
Plumbing  regulations  are  practically  a  set  of  trade  con- 
struction rules  which  should  be  administered  by  practical 
plumbing  inspectors  and  not  by  the  specially  trained  sani- 
tary inspectors  whose  services  are  required  for  duties 
directly  affecting  public  health.  The  minor  relation  of 
sewer  gas  to  health  under  ordinary  conditions  has  been 
indicated  in  a  previous  chapter;  even  were  that  relation 
more  important  than  is  now  thought  by  sanitarians,  it 
would  nevertheless  be  preferable  to  entrust  the  correctness 
of  plumbing  construction  to  those  who  make  a  specialty 
of  construction  rather  than  of  public  health.  Such  re- 
assignments  of  responsibility  need  not  deprive  the  health 
authorities  of  the  power  to  enforce  the  proper  disposal 
of  excreta  —  which   is   a   true  public   health   function  — 

1  This  seems  the  best  term  to  distinguish  those  nuisances  which  do 
not  primarily  or  largely  affect  public  health.  The  word  "  sanitary- "  is 
here  used  in  its  true  significance  of  "  relating  to  Jiealth,"  not  in  its 
popular  sense  referring  largely  to  cleanliness. 


446  A   MANUAL   FOR   HEALTH  OFFICERS 

or  even  of  enforcing  general    inunicii:)al   cleanliness  when 
need  be. 

It  has  been  suggested  that  the  police  might  well  handle, 
or  assist  in  handling,  many  of  the  ordinary  nuisances  — 
such  as  those  relating  to  cleanliness  of  yards,  care  of  gar- 
bage and  other  refuse,  etc.  —  which  now  take  up  a  great 
deal  of  the  routine  attention  of  health  departments.  The 
police  already  deal  with  nuisances  due  to  spitting,  snow  on 
sidewalks,  weeds  and  the  like,  and  with  the  relatively  much 
greater  number  of  patrolmen  than  sanitary  inspectors  it 
would  appear  a  prima  facie  possibility  to  deal  promptly 
and  effectively  with  other  kinds  of  nuisances,  many  of 
which  could  be  remedied  through  simple  oral  notification. 
Offenders  could  be  prosecuted  by  direct  police  procedure. 
Only  conditions  actually  of  direct  danger  to  health  would 
need  to  be  referred  to  the  health  department,  or  those 
concerning  which  the  patrolman  has  some  doubt.  The 
idea  has  been  developed  by  Gunn,^  who  states  that  the 
majority  of  the  police  chiefs  who  were  questioned  granted 
the  feasibility  of  such  cooperation.  The  idea  has  a  great 
deal  to  recommend  it,  and  if  adopted  it  would  leave  the 
health  department  freer  to  attack  matters  much  more 
closely  related  to  health,  but,  so  far  as  the  writer  knows,  It 
has  not  thus  far  been  practically  tried  out  m  extenso  any- 
where in  this  country.  In  any  case  a  closer  degree  of  co- 
operation should  be  developed  than  now  exists  between 
the  average  health  and  police  departments. 

In  many  communities  it  is  now  the  custom  to  have  an 
annual  "clean-tip"  day  or  week  for  the  collection  and  dis- 
posal of  the  miscellaneous  debris  and  refuse  which  has 
accumulated  during  the  year.  Health  departments  may 
cooperate  in  such  activities  if  they  will  thus  be  saved  a 
great  deal  of  routine  nuisance  notification  during  the  year. 

'  Gunn,  "  The  Need  for  a  More  General  Cooperation  between 
Health  and  PoHce  Departments,"  Am.  Jour.  Pub.  Health,  1913,  vol. 
in,  no.  4,  p.  318. 


NUISANCES  447 

The  amount  of  material  from  houses,  cellars,  vacant  lots, 
etc.,  which  may  thus  be  removed  in  a  thorough  and  well- 
advertised  clean-up  is  large,  often  necessitating  temporary 
provision  of  extra  wagons  and  labor  by  the  municipality. 
Opportunity  should  be  taken  for  impressing  the  desirability 
of  prompt  removal  of  such  materials  during  the  year  so 
that  in  future  general  clean-ups  may  not  be  necessary. 

Inspections  and  Notifications.  —  i.  Inspections. —  If 
regular  house-to-house  inspections  are  performed  by  the 
health  department,  as  recommended  in  the  last  chapter, 
many  nuisances  will  be  discovered  in  that  manner.  Com- 
plaints will  also  be  received  and  if  there  is  any  apparent 
ground  for  them,  should  be  investigated  even  when  un- 
signed, for  the  reason  that  unsigned  complaints  of  condi- 
tions really  needing  attention  are  not  infrequently  made 
by  persons  who  are  apprehens'ive  of  having  trouble  with 
employer,  landlord  or  neighbors  if  their  identity  is  dis- 
covered. Although  many  complaints,  perhaps  the  majority 
even,  will  be  found  to  be  based  upon  misapprehension  or 
malice,  it  appears  best  that  all  which  are  not  on  their  face 
unjustified  should  receive  attention. 

2.  Notices  in  legal  form  should  be  served  on  the  person 
or  persons  responsible,  describing  the  nuisance,  advising 
them  to  abate  it  "forthwith"  or  within  a  stated  length  of 
time,  and  reciting  the  penalty  prescribed.  A  printed  slip 
copy  of  the  ordinance  violated  may  be  enclosed.  The  legal 
requirements  for  the  service  of  notices  should  be  ascer- 
tained from  counsel,  to  be  strictly  followed  in  all  cases. 
The  inspector's  notebook  should  show  a  record  of  each 
notice  served. 

In  some  cases,  at  the  discretion  of  the  health  ofificer,  a 
special  letter  may  be  written  instead  of  a  notice.  In 
Montclair,  N.  J.,  a  typewritten  letter  is  sent  out  in  each 
case,  no  printed  form  being  used. 

In  dealing  with  minor  nuisances  oral  notification  b>'  the 
inspector  and  the  use  of  notice  forms  which  may  be  filled 


44&  A  MANUAL   FOR   HEALTH  OFFICERS 

out  by  the  inspector  on  tlie  spot  will  be  found  useful. 
Such  nuisances  are  numerous  and  would  consume  a  great 
and  unwarrantable  amount  of  time  and  energy  if  office 
notices  were  made  out  in  all  cases. 

3.  Reinspections  are  made  in  due  course  and  reported 
back  to  the  office.  Nuisance  records  should  be  reviewed 
in  general  once  a  week. 

4.  Legal  remedies  have  been  considered  in  a  preceding 
section. 

I.   NUISANCES   INVOLVED   IN   DISPOSAL   OF 
WASTES 

/.   DISPOSAL  OF  EXCRETA 

By  far  the  most  important  class  of  nuisances  from  the 
public  health  standpoint  are  those  involved  in  the  disposal 
of  human  wastes.  It  is  a  first  duty  of  every  health  depart- 
ment to  insist  upon  the  disposal  of  such  a  matter  in  such  a 
way  that  the  public  health  is  safeguarded.  Excreta  should 
always  be  regarded  as  potentially  infected;  in  Chapter  I 
(under  Epidemiology)  has  been  pointed  out  the  danger 
arising  from  improper  disposal  in  a  single  case.  Proper 
disposal  means  prompt  removal  —  if  possible  by  means  of 
sewers  —  with  safeguards  against  contact  and  insect  in- 
fection and  pollution  of  water  supplies,  to  a  point  where 
the  wastes  are  not  a  source  of  danger.  This  principle 
applies  to  the  simplest  privy  and  to  the  largest  system  of 
sewers  and  sewage  treatment. 

Sewage  disposal  in  general  involves  two  considera- 
tions: The  prevention  of  nuisance  to  the  senses,  and  pre- 
vention of  infection.  The  former  is  too  obvious  to  require 
discussion;  we  shall,  therefore,  devote  our  attention  to  the 
latter. 

Where  sewers  exist,  an  ordinance  should  be  adopted  re- 
quiring the  connection  of  all  dwelling  houses  on  sewered 
streets  with  those  sewers  and  the  installation  of  adequate 


NUISANCES  449 

plumbing  appliances  (say  within  thirty  or  sixty  flays), 
followed  by  the  immediate  cleaning  out  and  abolition  of 
previously  existing  privy  vaults  and  cesspools.  Such  an 
ordinance,  persistently  enforced,  should  do  away  practi- 
cally entirely  with  the  privy  nuisance.  Any  privies  which 
remain  on  unsewered  streets  should  be  of  a  sanitary  type 
(see  below). 

Where  sewers  do  not  exist,  as  in  rural  and  semi-rural 
districts,  the  methods  of  disposal  of  excreta  should  be 
strictly  regulated.  Soil  pollution  and  the  spread  of  infec- 
tion from  unsanitary  privies  through  domestic  animals, 
flies,  etc.,  are  inexcusable  in  any  community.  Privies  and 
cesspools  are  an  additional  menace  where  domestic  water 
supplies  from  wells  exist  in  conjunction  with  them. 

I.  Privies.  ^  The  following  are  the  chief  requirements 
for  the  "sanitary  privy": 

1.  It  must  be  convenient  and  cleanly,  as  regards  both 
use  and  cleaning.  The  ventilation  should  be  adequate. 
Persons  will  not  properly  use  nor  properly  care  for  an 
offensive,  inconvenient  privy. 

2.  There  must  be  safeguards  against  danger  of  spread- 
ing infection.  Stiles  and  Lumsden  give  the  following 
desiderata  under  this  head: 

(o)  "The  excreta  must  not  touch  the  ground;  hence 
some  kind  of  water-tight  receptacle  (box,  pail,  tub,  barrel, 
tank  or  vault)  for  the  excreta  must  be  used  under  the  seat. 

(h)  "Domesticated  animals  must  not  have  access  to  the 
night  soil;  therefore,  the  privy  should  have  a  trapdoor  in 
the  back  to  exclude  them. 

(c)  "Flies  and  other  insects  must  not  have  access  to 
the  excreta;  therefore,  the  entire  privy  must  be  made 
rigidly  flyproof,  or  some  substance  must  be  used  in  the 
receptacle  to  protect  the  contents  from  insects." 

3.  The  final  disposal  of  the  contents  [frequently  called 
"night  soil,"  from  the  custom  in  some  places  of  removing 
at  night]  must  be  safe. 


45©  A  MANUAL   FOR   HEALTH  OFFICERS 

4-  The  cost  of  construction  and  care  must  not  be 
excessive. 

Full  and  detailed  directions  for  the  construction  and 
operation  of  sanitary  privies  may  be  obtained  in  the  Govern- 
ment bulletins  on  the  subject/  from  which  the  following 
excerpts  are  taken. 

Two  types  of  sanitary  privies  are  generally  recognized, 
namely,  the  so-called  "dry  system"  and  the  so-called  "wet 
system."  It  will  be  noted  that  the  above  authors  recom- 
mend a  properly  managed  "wet  system,"  of  which  a  special 
form   has  been  designed   (see  note  at  close  of  following 

quotation). 

THE   "  DRY   SYSTEM  " 

In  the  "  dry  system  "  privies  dry  earth,  road  dust,  wood  ashes  or 
lime  is  kept  in  the  privy,  and  is  scattered  on  the  excreta  every  time  the 
privy  is  used. 

The  dry  system,  if  properly  managed,  presents  the  following  ad- 
vantages : 

(i)    It  decreases  the  offensiveness  of  the  privy  contents. 

(2)  It  is  cheap. 

(3)  It  decreases  the  chance  of  spread  of  infection  by  insects. 

(4)  It  is  an  easy  system  to  manage. 

The  disadvantages  of  the  dry  system  are  the  following: 

(i)    It  is  very  difficult  to  make  a  dry  privy  rigidly  flyproof,  hence 

flies  usually  do  have  more  or  less  access  to  the  excreta,  on  which  they 

feed  and  on  which  they  lay  their  eggs. 

(2)  Its  efficiency  depends  upon  the  careful  and  faithful  cooperation 
of  all  persons  (including  children)  who  use  the  privy,  and  experience 
shows  that  such  cooperation  cannot  be  relied  upon. 

(3)  It  increases  the  amount  of  material  to  be  removed;  hence  it 
increases  the  labor  and  frequency  of  necessary  cleaning. 

(4)  Experience  shows  that  it  is  exceptional  that  the  excrement  is 
properly  covered  with  dry  earth  or  lime;  hence  the  system  is  not  so 
efficient  as  is  popularly  supposed. 

'  Farmers'  Bulletin  463,  U.  S.  Dept.  of  Agriculture:  "  The  Sanitary 
Privy"  (by  Stiles  and  Lumsden,  1911),  and  Public  Health  Bulletin 
No.  37,  U.  S.  Pub.  Health  Service:  "  The  Sanitary  Privy:  Its  Purpose 
and  Construction  "  (Stiles,  1910).  Special  attention  to  the  subject 
has  also  been  paid  by  the  southern  state  health  departments,  from  which 
information  and  plans  may  be  obtained. 


NUISANCES  451 

(5)  Neither  dry  earth  nor  lime,  in  practical  usage,  can  be  relied  upon 
to  destroy  all  disease  germs  which  may  be  in  the  excreta;  hence  their 
use  is  likely  to  give  rise  to  a  false  sense  of  security  in  the  public 
mind. 

(6)  If  the  dejecta  at  the  time  of  burial  contain  fly  j^ruhs  these 
larvae  may  crawl  through  the  earth  to  the  surface,  where  they  can 
complete  their  development  into  adult  flies  and  spread  infection  from 
the  buried  night  soil. 

Privies  of  the  "  dry  system  "  should  not  be  marked  more  than  75 
points  on  a  scale  of  100. 

THE   "  WET   SYSTEM  " 

In  the  "  wet-system  "  privies  some  fluid  is  used  in  the  receptacle 
either  (i)  to  disinfect  the  excreta,  or  (2)  to  act  as  an  insect  repellent, 
or  (3)  to  increase  the  destruction  of  disease  germs  in  the  excreta  by 
natural  fermentation. 

The  advantages  of  the  "  wet  system  "  are: 

(1)  It  decreases  the  offensiveness  of  the  privy  contents. 

(2)  It  is  cheap. 

(3)  It  greatly  decreases  the  chances  of  spread  of  infection  by  flies 
because  they  cannot  breed  in  the  excreta;  hence  rigid  fly  screening  is 
not  so  necessary. 

(4)  It  kills  or  renders  harmless  a  considerable  proportion  of  certain 
infections  contained  in  the  excreta. 

(5)  Its  efficiency  does  not  depend  upon  the  intelligence  or  coopera- 
tion of  all  persons  using  it. 

The  disadvantages  of  the  "  wet  system  "  are: 

(i)  It  is  more  difficult  to  keep  clean  than  the  "  dn,'  system,"  be- 
cause of  the  danger  of  soiling  the  floor  when  the  receptacle  is 
emptied. 

(2)  Unless  the  receptacle  is  very  deep  there  is  likely  to  be  more  or 
less  splashing. 

(3)  The  labor  and  frequency  of  cleaning  are  about  the  same  as  in 
the  case  of  the  "  dry  system." 

If  the  wet  system  is  used  It  is  best  to  fill  the  receptacle  about  one- 
fourth  full  of  water,  on  the  surface  of  which  a  cup  of  petroleum  is  poured. 
The  petroleum  acts  as  an  insect  repellent. 

Two  sets  of  receptacles  should  be  provided.  While  one  set  is  being 
used  under  the  seat,  the  other  set  is  covered  and  permitted  to  stand  so 
as  to  lengthen  the  period  of  fermentation.^ 

1  Farmers'  Bull.  463,  pp.  15-17.  The  L.  R.  S.  (Lumsden,  Roberts 
and  Stiles)  wet-system  privy  is  fully  described  in  this  bulletin. 


452  A   MANUAL   TOR   HEALTH   OFFICERS 

The  above  remarks  relate  to  i:)n)perl>'  constructed  out- 
houses, concerning  wliicli  llie  following  general  directions 
apply.' 

HOW  TO  BUILD   AND   CARE   FOR   A   PRIVY 

The  following  are  the  essential  features:  There  is  (A)  a  closed  portion 
(box)  under  the  seat  for  the  reception  (in  a  receptacle)  and  safeguarding 
of  the  excreta;  (B)  a  room  for  the  occupant;  and  (C)  there  is  proper 
ventilation. 

A.  The  receptacle  consists  practically  of  a  box,  with  a  top  repre- 
sented by  the  seat,  with  a  floor  which  is  a  continuation  of  the  floor  of 
the  room,  with  a  front  extending  from  the  seat  to  the  floor,  with  a 
hinged  back  which  should  close  tightly,  and  with  two  sides  continuous 
with  the  sides  of  the  room  and  provided  with  wire  screened  venti- 
lators, the  upper  margin  of  which  is  just  under  the  level  of  the  seat. 
The  seat  should  have  one  or  more  holes  according  to  the  size  of  the 
privy  desired,  and  each  hole  should  have  a  hinged  lid  which  lifts  up 
toward  the  back  of  the  room;  there  should  be  a  piece  of  wood  nailed 
across  the  back,  on  the  inside  of  the  room,  so  as  to  prevent  the  lids 
from  being  lifted  sufficiently  to  fall  backward  and  so  as  to  make  them 
fall  forward  of  their  own  accord  as  soon  as  the  person  rises.  In  this 
box  there  should  be  one  or  more  water-tight  tubs,  half  barrels,  pails 
or  galvanized  cans,  corresponding  to  the  number  of  holes  in  the  seat. 
This  receptacle  should  be  high  enough  to  reach  nearly  to  the  seat,  or, 
better  still,  so  as  to  fit  snugly  against  the  seat,  in  order  to  protect  the 
floor  against  soiling,  and  sufificiently  deep  to  prevent  splashing  the 
person  on  the  seat;  it  should  be  held  in  place  by  cleats  nailed  to 
the  floor  in  such  a  way  that  the  tub  will  always  be  properly  centered. 
The  back  should  be  kept  closed. 

B.  The  room  should  be  water-tight  and  should  be  provided  in  front 
with  a  good,  tightly  fitting  door.  The  darker  this  room  can  be  made 
the  fewer  flies  will  enter.  The  roof  may  have  a  single  slant  or  a  double 
slant,  but  while  the  double  slant  is  somewhat  more  sightly,  the  single 
slant  is  less  expensive  on  first  cost.  The  room  should  be  provided  with 
two  or  three  wire-screened  ventilators,  as  near  the  roof  as  possible. 

C.  The  ventilators  are  very  important  additions  to  the  privy,  as 
they  permit  a  free  circulation  of  air  and  thus  not  only  reduce  the  odor 
but  make  the  outhouse  cooler.  These  ventilators  should  be  copper 
wire  screened  in  order  to  keep  out  flies  and  other  insects.  There  should 
be  at  least  4  (better  5)  ventilators,  arranged  as  follows:  One  each  side 
of  the  box;  one  each  side  the  room  near  the  roof;  and  a  fifth  ventilator, 
over  the  door,  in  front,  is  advisable. 

'  For  further  details  see  the  Bulletins  already  referred  to. 


NUISANCES  453 

Latticework,  flowers  and  vines.  —  At  IjcsI,  llic  privy  is  not  an  at- 
tractive addition  to  the  yard.  It  is  i)ossiljlc,  liowever,  to  reduce  its 
unattractiveness  by  surfoiiiiding  it  with  a  latticeworic  on  which  are 
trained  vines  or  Ilowers.  This  plan,  wliicli  adds  but  little  to  the  ex- 
pense, renders  the  building  much  less  unsiglitly  and  much  more  private. 

Disinfectant.  —  It  is  only  in  comparatively  recent  years  that  the 
privy  has  been  thought  worthy  of  scientific  study,  and  not  unnaturally 
there  is  some  difference  of  opinion  at  present  as  to  the  best  i>lan  to 
follow  in  regard  to  disinfectants. 

["  Dry  system":] 

(a)  Top  soil.  —  Some  persons  prefer  to  keep  a  box  or  a  barrel  of 
top  soil,  sand  or  ashes  in  the  room  and  to  recommend  that  each  time 
the  privy  is  used  the  excreta  be  covered  with  a  shoveful  of  the  dirt. 
While  this  has  the  advantage  of  simplicity,  it  has  the  disadvantage 
of  favoring  carelessness,  as  people  so  commonly  (in  fact,  as  a  rule)  fail 
to  cover  the  excreta;  further,  in  order  to  have  the  best  results,  it  is 
necessary  to  cover  the  discharges  very  completely;  finally,  at  best,  our 
knowledge  as  to  how  long  certain  germs  and  spores  will  live  under  these 
conditions  is  very  unsatisfactory. 

{b)  Lime.  —  Some  persons  prefer  to  have  a  box  of  lime  in  the  room 
and  to  cover  the  excreta  with  this  material.  Against  this  system 
there  is  the  objection  that  the  lime  is  not  used  with  sufficient  frequency 
or  liberality  to  keep  insects  away,  as  is  shown  by  the  fact  that  flies 
carry  the  lime  to  the  house  and  deposit  it  on  the  food. 

["  Wet  system  ":] 

(c)  Water  and  oil.  —  A  very  cheap  and  simple  method  is  to  pour 
into  the  tub  about  2  or  3  inches  of  water;  this  plan  gives  the  excreta 
a  chance  to  ferment  and  liquefy  so  that  the  disease  germs  may  be  more 
easily  destroyed.  If  this  plan  is  followed  a  cup  of  oil  (kerosene  will 
answer)  should  be  poured  on  the  water  in  order  to  repel  insects. 

{d)  Cresol.  —  Some  persons  favor  the  use  of  a  5  per  cent  crude 
carbolic  acid  in  the  tub,  but  probably  the  compound  solution  of  cresol 
(U.  S.  P.)  will  be  found  equally  or  more  satisfactory  if  used  in  a  strength 
of  I  part  of  this  solution  to  19  parts  of  water. 

If  a  disinfectant  is  used  the  family  should  be  warned  to  keep  the 
reserve  supply  in  a  place  that  is  not  accessible  to  the  children,  other- 
wise accidents  may  result. 

Cleaning  the  Receptacle.  —  The  frequency  of  cleaning  the  re- 
ceptacle depends  upon  (a)  the  size  of  the  tub,  {b)  the  number  of  persons 
using  the  privy  and  (c)  the  weather.  In  general,  it  is  best  to  clean  it 
about  once  a  week  in  winter  and  twice  a  week  in  summer. 

An  excellent  plan  is  to  have  a  double  set  of  pails  or  tubs  for  each 
privy.  Suppose  the  outhouse  is  to  be  cleaned  every  Saturday:  Then 
pail  No.  I  is  taken  out  (say  January  i),  covered  and  set  aside  until 
the  following  Saturday;    pail  No.  2  is  placed  in  the  box  for  use;    on 


454  A   MANUAL   FOR   HEALTH  OFFICERS 

January  8  pail  No.  i  is  emptied  and  put  back  in  the  box  for  use  while 
pail  No.  2  is  taken  out,  covered  and  set  aside  for  a  week  (namely,  until 
January  15);  and  so  on  throughout  the  year.*  The  object  of  this  plan 
is  to  give  an  extra  long  time  for  the  germs  to  be  killed  by  fermentation 
or  by  the  action  of  the  disinfectant  before  the  pail  is  emptied. 

Each  time  that  the  receptacle  is  emptied,  it  is  best  to  sprinkle  into 
it  a  layer  of  top  soil  about  a  quarter  to  half  an  inch  deep  before  putting 
it  back  into  the  box. 

DiSPOS.\L  OF  THE  E.XCRETA.  —  For  the  present,  until  certain  very 
thorough  investigations  are  made  in  regard  to  the  length  of  time  that 
the  eggs  of  parasites  and  the  spores  of  certain  other  germs  may  live 
under  various  plans,  it  is  undoubtedly  best  to  burn  or  boil  all  excreta; 
where  this  is  not  feasible,  it  is  best  to  bury  all  human  discharges  at  least 
300  feet  away  and  down  hill  from  any  water  supply  (as  the  well,  spring, 
etc.). 

Many  farmers  insist  upon  using  the  fresh  night  soil  as  fertilizer. 
In  warm  climates  this  is  attended  with  considerable  danger,  and  if 
it  is  so  utilized,  it  should  never  be  used  upon  any  field  upon  which 
vegetables  are  grown  which  are  eaten  uncooked;  further,  it  should 
be  promptly  plowed  under. 

In  our  present  lack  of  knowledge  as  to  the  length  of  time  that  various 
germs  (as  spores  of  the  ameba  which  produce  dysentery,  various  eggs, 
etc.)  may  live,  the  use  of  fresh,  ufiboiled  night  soil  as  a  fertilizer  is  false 
economy  which  may  result  in  loss  of  human  life.  This  is  especially  true 
in  warm  climates.^ 

It  is  estimated  that  the  cost  of  materials  for  a  sanitary 
type  of  privy  on  the  above  principles  will  be  from  $5  to 
$10,  according  to  locality,  to  which  must  be  added  carpenter 
or  home  labor. 

Multiple  privies  on  the  above  principles  may  be  con- 
structed for  schools,  hotels,  etc. 

Every  board  of  health  should  have  an  ordinance  requiring 
privies  (where  necessary)  to  be  constructed  and  cared  for, 
not  necessarily  according  to  a  fixed  plan,  but  at  least 
according  to  sanitary  principles  and  subject  to  the  approval 
of  the  health  authorities. - 

'  Pub.  Health  Bull.  No.  37,  pp.  8-1 1. 

^  The  possible  development  of  patent  sanitary  closets  is  worthy  of 
note.  Such  a  closet,  designed  for  use  anywhere  in  the  house,  is  manu- 
factured by  the  West  Disinfecting  Co.,  12  East  42nd  St.,  New  York 
City.  Such  devices  must  be  judged  according  to  their  cost  and  their 
merit  as  demonstrated  in  practical  use. 


NUISANCKS  455 

Disposal  of  Night  Soil.  —  Special  attention  should  he 
paid  to  the  disposal  of  night  soil,  on  which  some  remark  is 
made  in  the  (juotation  above.  Since  the  ideal  method  of 
burning  or  boiling  is  impracticable  to  enforce  generally, 
reliance  must  usually  be  placed  upon  proper  burial  Cnot 
less  than  two  feet  deep)  in  a  safe  place,  preferably  with  the 
use  of  a  disinfectant  (chloride  of  lime,  etc.).  It  must  be 
remembered,  however,  that  this  is  not  an  ideal  method,  for 
disease  germs  may  later  come  to  the  surface,  any  fly  grubs 
present  are  not  killed  but  may  come  to  the  top  through  as 
much  as  six  feet  of  sand,  and  there  is  the  possibility  of 
contaminating  water  supplies,  especially  in  a  limestone 
region.  The  great  danger  in  the  use  of  night  soil  as  fer- 
tilizer (mixed  or  unmixed  with  manure)  is  referred  to  above. 
Owing  to  the  impossibility  of  knowing  which  persons  in  a 
community  are  excreting  disease  germs,  all  excreta  (stools 
and  urine)  must  be  regarded  as  a  virulent  poison  to  be 
disposed  of  accordingly."^  Provision  should  also  be  made 
for  sufficiently  frequent  removal  of  contents  to  prevent 
danger  of  overflow.  In  Asheville,  N.  C,  a  city  having 
sanitary  privies  and  municipal  removal,  a  maximum  period 
of  fifteen  days  is  prescribed.  The  period  may,  however, 
vary  somewhat,  according  to  circumstances. 

Temporary  Privies.  —  In  connection  w4th  construc- 
tion work  on  new  houses,  etc.,  street  w^ork  and  other  works 
where  laborers  are  employed,  temporary  privies  should  be 
required  and  the  commission  of  nuisances  be  forbidden. 
Cooperation  may  be  established  with  the  building  inspec- 
tion department,  so  as  to  obtain  notice  of  constructions  to 
be  started.  Such  privies  should  be  constructed  on  ap- 
proved lines,  a  permit  from  the  health  department  being 
required.  The  foreman  or  other  person  in  charge  should 
be  held  strictly  responsible  for  their  construction  and  care. 
It  should  be  prescribed  that  there  be  a  proper  water- 
tight receptacle  and  that  the  contents  be  kept  constantly 
^  For  further  details  see  Farmers'  Bulletin  463,  pp.  30-32. 


456  A   MANUAL   FOR   HEALTH   OFFICERS 

covered  with  unslaked  lime,  chloride  of  lime,  water  with  a 
film  of  kerosene  (see  directions  for  "wet  system,"  above)  or 
other  satisfactory  substance,  and  that  the  contents  be  suffi- 
ciently frequently  remo\ed  and  disposed  of  in  accordance 
with  the  sanitary  ordinances,  the  receptacle  being  finally 
cleaned  out  and  disinfected  as  soon  as  there  is  no  longer  any 
necessity  for  use. 

Similar  precautions  should  be  taken  in  regard  to  picnic 
grounds  and  other  places  where  temporary  gatherings  of 
people  take  place.  Such  places,  if  regularly  used,  should 
be  provided  with  permanent  sanitary  privies. 

Privy-cleaning  Service.  —  Granted  that  the  health 
department  has  an  ordinance  covering  completely  the 
subject  of  privies  and  disposal  of  excreta,  the  question  of 
systems  of  removal  of  night  soil  arises.  In  many  communi- 
ties having  privies  such  removal  is  performed  by  private 
scavengers,  who  should  be  strictly  licensed,  subject  to  the 
approval  of  the  health  authority  regarding  their  methods  of 
collection  and  disposal.  The  following  remarks,  applying 
both  to  towns  and  to  rural  districts,  are  taken  from  Stiles.^ 

Since,  from  a  sanitary  point  of  view,  the  privy  is  a  public  structure, 
in  that  it  influences  public  health,  it  seems  wisest  to  have  city  and 
town  ordinances  which  provide  for  a  licensing  of  all  privies,  the  license 
being  fixed  at  a  sum  which  will  enable  the  city  or  town  to  provide  the 
receptacle  (tub,  pail,  etc.),  the  disinfectant  and  the  service  for  cleaning. 
The  expense  involved  will  vary  according  to  local  conditions,  such  as 
cost  of  labor  and  density  of  population.  If  the  "  chain  gang  "  can  be 
utilized  for  cleaning,  the  expense  for  labor  is  reduced. 

The  importance  of  taking  the  responsibilit>-  for  the  care  of  the 
privy  out  of  the  hands  of  the  family  is  evident  when  one  considers 
that  one  careless  family  in  ten  or  in  a  hundred  might  be  a  menace  to 
all.  Quite  generally  the  removal  of  garbage  and  of  ashes  is  recognized 
as  a  function  of  the  city  or  town  in  all  better  organized  communities, 
and  the  idea  is  constantly  spreading  that  this  service  should  extend  to 
a  removal  of  the  night  soil  also. 

In  correspondence  with  certain  cotton  mills  estimates  for  privy 
cleaning  (once  a  week)  vary  from  about  20  to  25  cents  per  privy  per 

1  Pub.  Health  Bull.  No.  37,  pp.  15,  16. 


NUISANCES  457 

month.  A  privy  tax  of  $3.50  to  $5  jjcr  i)rivy  per  year  ought  to  {/ive 
satisfactory  service,  including  receptacle,  but  the  exact  amount  of  the 
tax  must  be  determined  by  experience  in  each  locality. 

It  is  probably  the  exception  that  an  economical  public  privy-cleaning 
service  can  be  carried  out  in  the  open  country,  on  account  of  the  dis- 
tances between  the  houses.  To  meet  the  difficulties  involved,  several 
suggestions  may  be  considered,  according  to  conditions:  A  county 
privy  tax  can  be  levied,  the  county  can  furnish  the  pail  and  the  dis- 
infectant, and  (i)  one  member  of  each  family  or  of  several  neighboring 
families  hired  to  clean  the  privy  regularly;  or  (2)  the  landlord  can  be 
held  responsible  for  the  cleaning  of  all  privies  of  his  tenants,  receiving 
from  the  county  a  certain  sum  for  the  service;  or  (3)  "  trusties  "  from 
prisons  might  possibly  be  utilized  in  some  districts  not  too  sparsely 
settled;  or  (4)  a  portion  of  the  county  privy  tax  might  perhaps  be 
apportioned  by  school  districts  and  be  distributed  as  prizes  among  the 
school  boys  who  keep  their  family  privy  in  best  condition;  or  (5)  each 
head  of  family  might  be  held  responsible  for  any  soil  pollution  that  may 
occur  on  his  premises  and  be  fined  therefor. 

Undoubtedly  the  problem  of  the  privy  cleaning  in  the  open  country 
is  much  more  difficult  than  in  cities,  villages  and  towns,  and  in  the  last 
instance  involves  a  general  education  of  the  rising  generation  of  school 
children,  more  particularly  of  the  girls  (the  future  housekeepers),  in 
respect  to  the  dangers  of  soil  pollution. 

2.   Cesspools  and  Domestic  Sewage  Disposal  Systems,  — 

The  construction  and  care  of  cesspools  should  be  super- 
vised in  the  same  way  as  that  of  privies.  Two  types  of 
cesspool  are  to  be  recognized :  (i)  the  tight  cesspool,  and  (2) 
the  leaching  cesspool.  Each,  according  to  circumstances, 
has  its  value.  Where  there  is  no  danger  of  the  pollution  of 
wells,  etc.,  the  leaching  type  may  be  permitted  and  with 
right  soil  conditions  may  prove  a  highly  effective  and  com- 
mendable method  of  sewage  disposal.  In  this  case  the  soil 
acts  as  a  natural  filter.  Sandy  soils  are  best,  while  clay  and 
limestone  are  to  be  distrusted.  In  regard  to  the  protection 
of  wells,  etc.,  in  the  vicinity,  it  must  be  remembered  that 
intestinal  organisms  may  still  be  carried  somewhat  beyond 
the  zone  in  which  oxidation  of  organic  matters  takes  place. 
Where  it  is  necessary  for  the  prevention  of  soil  pollution 
to  use  a  tight  cesspool,  a  plan  should  be  submitted  and  a 


458  A   MANUAL   FOR   HEALTH  OFFICERS 

permit  be  required  before  it  is  begun  and  again  before  it 
is  put  in  use,  so  that  the  health  authorities  may  satisfy 
themselves  that  the  construction  is  water-tight  and  suffi- 
ciently substantial  to  remain  so.  With  this  type  of  cesspool 
cleaning  out  must  be  sufficiently  frequent,  and  the  contents 
must  be  disposed  of  under  the  same  regulations  that  apply 
to  privies. 

Cesspools  of  either  type  should  be  so  covered  as  to  prevent 
the  access  of  flies  and  mosquitoes. 

Domestic  sewage  disposal  systems  for  rural  and  semi- 
rural  districts  should  be  constructed  on  scientific  plans 
adapted  to  local  conditions  and  under  the  supervision  of  the 
health  authorities,  who  should  require  a  permit  for  the  be- 
ginning of  such  work  and  another  final  permit  when  the 
system  is  completed  and  before  it  is  put  in  use.  Suitable 
plans  and  advice  may  be  obtained  from  competent  sanitary 
engineers  and  from  the  engineering  divisions  of  state 
health  departments.' 

The  menace  to  health  from  the  discharging  of  undisin- 
fected  sewage  and  sewage  disposal  effluents  into  water- 
courses which  may  be  used  as  water  supplies  is  obvious  and 
need  not  be  dwelt  upon  here;  nor  can  the  subject  of  munic- 
ipal sewage  disposal  be  discussed.^  Methods  of  determin- 
ing when  sewage  pollution  by  leaching  and  otherwise  is 
taking  place  have  already  been  mentioned  (Chap.  IV). 

II.    DISPOSAL  OF  OTHER  WASTES 

We  now  come  to  a  class  of  nuisances  having  much  less 
bearing  upon  public  health  than  those  of  the  class  just 
mentioned  (in  fact  in  many  cases  no  bearing  at  all),  but 
which  consume  much  of  the  routine  attention  of  health 

'  Cf.  Bashore,  "  Sanitation  of  a  Country  House  ";  Gerhard,  "  The 
Disposal  of  Household  Wastes";  and  Gerhard,  "The  Sanitation, 
Water  Supply,  and  Sewage  Disposal  of  Country  Houses." 

*  See  Rosenau,  "  Prev^entive  Medicine  and  Hygiene,"  1913,  sec.  VII 
(by  G.  C.  Whipple). 


NUISANCES 


459 


departments.  These  relate  chiefly  l(j  the  i)rf)nif)lif)n  oi  gen- 
eral munici|)al  cleanlint'ss,  the  iiilluence  of  which  f;n  piihlic 
health  is  largely  indirect. 

Municipal  refuse  is  specified  by  Hering  '  as  follows: 
garbage,  dead  animals,  night  soil  (which  we  except  in  our 
remarks  under  this  section),  manure,  street  sweepings, 
ashes  and  rubbish. 

The  permissible  methods  of  disposing  of  these  various 
classes  (omitting  night  soil),  with  the  several  end-results 
or  products,  are  summarized  by  the  same  authority  ^  as 
follows : 


Refuse 

Incineration 

Reduction 

Burial  or 

plowing  into 

ground 

Dumping 

Feeding 

Garbage 

Steam    and 
ashes 

ditto 
ditto 

ditto 
Steam    and 

clinker 
Steam    and 
ashes  with 
or      with- 
out    prior 
picking 

Grease  and 
fertilizer 

ditto 

Decomposi- 
tion   and 
fertilizer 

ditto 

ditto 

ditto 

Food  for  pigs 

Dead  animals . . . 

Land  mak- 
ing' 
ditto  1 
ditto' 

ditto' 

Rubbish 

'  Not  always  advisable. 

2  The  disposal  of  manure  by  rotting  has  also  been  proposed,  the  claim  being  that  if 
the  manure  is  stacked  in  suitable  quantities  and  places  the  resulting  fermentation  will 
result  in  a  sufficiently  high  temperature  to  kill  eggs  and  maggots.  The  author  has, 
however,  no  definite  information  as  to  the  effectiveness  of  this  process.  ^  J.  S.  M. 

Where  incineration  is  adopted,  it  will  be  seen  it  can  be 
applied  to  all  classes  of  refuse,  and  night  soil  can  also  be 
most  safely  disposed  of  by  this  method. 

The  question  as  to  w^hat  method  or  methods  shall  be 
adopted  by  any  community  involves  consideration  of  local 

^  Hering,  "  Disposal  of  City  Refuse,"  Tra?ts.  XV  Internal.  Congress 
on  Hyg.  and  Demogr.,  1912,  vol.  IV,  pt.  II,  p.  398. 
2  Loc.  cit. 


460  A  MANUAL   FOR   HEALTH   OFFICERS 

conditions  and  costs,  and  since  it  relates  primarily  to  sani- 
tary or  municipal  engineering,  need  not  be  taken  up  here.^ 
The  supcnnsion  of  sanitary  authorities  over  refuse  may  be 
considered  under  two  heads. 

/.  Prevention  of  Unnecessary  Nuisance.  —  This  requires 
that  the  methods  of  householders  and  collectors  of  refuse 
be  careful  and  cleanly,  that  garbage  and  offal  cans  be  water- 
tight and  properly  covered  (to  prevent  odor  and  the  access 
of  flies  and  domestic  animals),  that  they  be  taken  in  as  soon 
as  emptied,  that  (where  the  separation  system  is  employed) 
garbage  be  kept  separate  from  other  refuse,  that  dead  ani- 
mals be  removed  promptly,  that  removal  of  all  refuse  be 
sufficiently  frequent,  and  the  like.  Also  that  final  methods 
of  disposal  be  proper,  forbidding  garbage  dumps  ^  and  the 
filling-in  of  land  with  garbage,  etc.  Private  scavengers 
should  be  licensed  so  as  to  insure  proper  control  of  their 
methods.  Refuse  collection  and  disposal  is  properly  a 
function  of  the  municipal  government  where  it  can  be 
economically  so  managed.  It  should,  however,  be  assigned 
to  some  department  other  than  the  health  department  — 
perhaps  most  appropriately  to  the  street-cleaning  authori- 
ties, 

2.  Prevention  of  Breeding  of  Flies,  Rats  and  Other  Vermin. 
—  The  care  of  stable  manure  has  a  special  bearing  on  the 
suppression  of  flies;  that  of  garbage,  on  the  reduction  of 
rats.  Fly  prevention  will  be  considered  in  detail  in  a  sub- 
sequent section. 

Beyond  these  latter  considerations  the  care  of  refuse 
has  practically  no  bearing  on  public  health,  but  is  rather 
a  matter  of  civic  cleanliness. 

Here,  in  general,  may  be  included  all  nuisances  relating 

1  See  Rosenau,  "  Preventive  Medicine  and  Hygiene,"  1913.  sec. 
Vni  (by  G.  C.  Whipple);  Papers  and  Rpts.  of  Committee  on  Refuse 
Collection  and  Disposal,  in  Am.  Jour.  Pub.  Health. 

2  Cf.  Terry,  "  The  Public  Dump  and  the  Public  Health,"  Am.  Jour. 
Pub.  Health,  1913,  vol.  HI,  no.  4,  p.  338. 


NUISANCFOS  461 

to  cleanliness  of  dwcllinK^s,  yards,  lots,  alleys,  streets, 
etc.,  which  need  not  be  six'cidcd.  In  many  communities 
the  alley  constitutes  a  special  problem  of  municipal 
cleanliness;  wherever  possible  alleys  should  be  taken  over 
and  cleaned  by  the  municipal  street-cleaning  flei)artment. 
We  need  scarcely  mention  the  disposal  of  dead  bodies,  of 
which  the  bearing  on  health  is,  under  normal  conditions, 
very  slight.  Cemeteries  were  formerly  thought  dangerous 
to  public  health  and  were  stringently  regulated,  but  now  it 
is  known  that  the  ordinary  cemetery  is  negligible  from  the 
health  standpoint,  except  as  underground  water  supplies 
may  possibly  be  contaminated  by  it. 

II.   NUISANCES   DUE   TO   INSECTS   AND    VERMIN 

/.    FLY  SUPPRESSION 

The  arguments  against  the  fly  as  a  vehicle  of  disease 
which  were  indicated  in  Chapters  I  and  II  indicate  fly 
suppression  to  be  a  duty  of  health  authorities.  It  was 
shown  that  both  the  house  fly  and  the  stable  fly  may  con- 
vey infection  (typhoid  fever  and  other  diseases)  mechani- 
cally (on  feet  and  proboscis),  and  the  stable  fly  through  its 
bite  (poliomyelitis,  anthrax,  etc.). 

The  epithet  "filth  fly"  implies  that  the  disposal  of  certain 
kinds  of  refuse  —  notably  stable  manure  —  quite  aside 
from  the  question  of  nuisance  in  the  popular  sense  of  the 
word,  has  a  public  health  bearing  in  the  breeding  and  at- 
traction of  flies.  The  epithet  applies  particularly  to  the 
fly  as  a  conveyer  of  infection  from  privy  vaults. 

The  importance  of  the  problem  in  any  given  case  depends 
upon  (i)  the  facilities  for  fly-breeding  (especially  in  stable 
manure),  (2)  the  length  and  warmth  of  the  summer  season, 
and  (3)  the  opportunities  for  infection  (in  typhoid  fever, 
etc.,  exposed  infectious  material;  in  poliomyelitis,  etc., 
infected  persons).  Favorable  conditions  for  fly  transmis- 
sion of  disease  may  be  found  to  a  greater  or  lesser  extent 


462  A   MANUAL   FOR    HEALTH   OFFICERS 

in  all  parts  of  the  country.  As  regards  typhoid  fever  and 
other  intestinal  diseases,  conditions  require  attention  in 
unsewered  or  partly  sewered  communities,  especially  in  the 
South,  having  the  combination  of  flies  and  unprotected 
privy  vaults.  It  is  unfortunate  that,  except  in  certain 
instances,  the  data  regarding  the  transmission  of  disease 
by  flies  are  indefinite.     (Cf.  pages  190,  209.) 

Where  and  How  Flies  Breed.  —  The  vast  majority  — 
in  many  communities  practically  all  —  of  common  house- 
flies  breed  in  horse  manure,  the  remainder  in  decaying 
organic  matter  of  various  kinds,  as  human  excrement,  ani- 
mal carcasses,  garbage  and  the  like.  The  stable  fly  (which 
has  a  predilection  for  biting  horses  and  cattle,  though 
it  also  bites  persons)  also  breeds  in  horse  manure,  though 
more  frequently  in  fermenting  heaps  of  grass,  cow-dung, 
brewer's  refuse  ("spent  hops"),  etc.  Flies  in  the  course 
of  their  life  history  pass  through  four  stages:  (i)  egg, 
(2)  larva  or  maggot,  (3)  pupa,  or  grub,  and  (4)  adult 
insect.  The  complete  development  of  the  house  fly  takes, 
under  favorable  circumstances,  about  ten  days;  that 
of  the  stable  fly  is  slower,  taking  nearly  a  month.  The 
larva  (white)  and  the  pupa  in  its  case  (brown)  may  be 
readily  seen  with  the  naked  eye;  the  eggs  (white)  are  some- 
what difficult  to  distinguish  without  the  aid  of  a  magnifying 
glass. 

As  to  the  prolificness  of  the  house  fly,  Howard  found  that 
120  eggs  are  laid  by  a  single  female  (more  have  been  noted), 
and  that  a  generation  is  produced  every  ten  days  at  the 
summer  temperatures  of  Washington.  This  would  mean 
twelve  generations  in  a  summer,  with  the  possibility  of 
countless  millions  from  a  single  fly  during  a  single  season. 
Even  did  only  a  small  percentage  survive,  the  rapidity  of 
propagation  is  evident.  Two  lessons  may  be  gathered  from 
this:  (i)  that  the  time  to  begin  fly-suppressive  measures  is 
the  early  spring,  and  (2)  that  if  breeding  places  are  avail- 
able a  very  few  flies  can  produce  a  very  great  crop. 


NUISANCES  463 

Measures  Against  Flies.  —  We  shall  discuss  first  and 
chiefly  the  care  of  stable  manure  (in  which  ninety  per  cent 
or  more  of  flies  breed),  but  similar  remarks  apply  also  to 
other  refuse  in  which  breeding  may  take  place. 

I.  Removal  and  Disposal  of  Manure.  —  The  fre- 
quent and  regular  removal  of  stable  manure  is  the  only 
thoroughly  practicable  general  measure  known  at  the 
present  time.  To  prevent  flies  from  laying  their  eggs  in 
stable  manure  is  practically  impossible,  for  this  material 
becomes  fly-blown  immediately  it  is  excreted;  but  if  it  be 
placed  promptly  in  tight  bins,  barrels  or  pits  and  removed 
regularly  once  a  week  during  the  fly  season  (so  as  to  allow  a 
margin  under  the  ten  days  necessary  for  the  eggs  to  hatch), 
fly-breeding  in  manure  within  the  city  limits  can  be  entirely 
eliminated.^  It  is  advisable  that  manure  be  removed  by 
the  municipal  authorities  in  towns  as  other  kinds  of  refuse 
are  removed.  Private  collections  are  likely  to  be  irregular 
for  the  reason  that  farmers  do  not  care  to  remove  manure 
during  the  busy  summer  months,  when  there  is  less  use  for 
it  as  fertilizer,  yet  this  is  just  the  time  when  the  public 
health  demands  that  it  be  frequently  moved.  Under 
municipal  collection  manure  might  be  stored  and  sold  at 
the  times  when  in  demand,  and  moderate  fees  for  removal 
would  make  up  the  expense. - 

1  From  the  health  department  of  a  southern  city  (Asheville,  N.  C.) 
we  have  the  following  statement:  "  The  proper  disposal  of  manure, 
which  we  know  to  be  the  main  breeding  place  of  the  fly,  leads  to  many 
arguments.  Many  people  wish  to  keep  the  manure  for  fertilizing  pur- 
poses, and  think  that  by  placing  it  under  the  surface  that  they  have 
gotten  rid  of  the  fly  problem.  Again,  if  the  manure  bin  is  screened  a 
false  sense  of  security  is  established  which  is  sure  to  throw  discredit  on 
the  fly  work  later  in  the  summer.  All  manure  that  goes  into  the  bin 
is  sure  to  be  infected  with  fly  eggs,  and  as  the  young  flies  just  leaving 
the  chrysalis  are  perfectly  able  to  crowd  through  the  meshes  of  the 
screen,  the  screening  is  of  no  avail.  Our  conclusion,  therefore,  is  that 
the  manure  bin  should  he  constructed  with  the  single  idea  of  being  thoroughly 
cleaned  out,  and  it  should  he  cleaned  out  not  less  than  once  a  "week.'' 

^  See  Hall,  "  Disposal  of  Manure,"  Am.  Jour.  Pub.  Health,  1914, 
vol.  IV,  no.  I,  p.  38. 


464  A   MANUAL  FOR   HEALTH  OFFICERS 

Removal,  of  course,  does  not  result  in  absolute  preven- 
tion of  breeding,  but  simply  in  the  transportation  of  the 
fl>-brecding  manure  to  some  more  or  less  distant  place 
(usually  to  the  country  for  fertilizer).  There  the  eggs 
already  present  (as  well  as  those  later  deposited)  will  hatch 
out  even  if  the  manure  is  buried  or  plowed  under  ground 
(tiy  grubs  have  been  known  to  emerge  through  six  feet  of 
sandy  soil).  Such  methods  protect  the  towns  which  en- 
force removal  of  manure,  but  the  general  prevention  of 
breeding,  including  the  country  districts,  is  a  much  more 
difficult  problem  and  one  which  has  not  yet  been  practi- 
cally solved. 

For  methods  of  disposal  of  manure  see  page  459. 

2.  Ground-Proofing.  —  A  certain  amount  of  breeding 
may  take  place  in  the  soil  under  and  around  stables,  in  old 
stray,  decayed  urine-soaked  boards,  etc. ;  hence  the  flooring 
of  stables  should  be  watertight  and  well  drained  and  general 
cleanliness  and  good  repair  should  be  observ^ed. 

3.  Chemical  Treatment.  —  As  direct  measures  for 
killing  the  larvae  and  insects  in  the  course  of  their  develop- 
ment, various  chemical  substances  have  been  employed, 
such  as  Paris  green  (recommended  by  U.  S.  Public  Health 
Service)  and  copperas  solutions,  kerosene  and  other  in- 
secticides.^ 

Regular  treatment  cannot,  of  course,  be  secured  unless 
frequent  inspections  are  made  to  apply  the  insecticide  or 

'  From  Asheville,  N.  C,  where  special  attention  has  been  devoted 
to  the  fly  problem,  comes  the  following  recommendation:  "  Some 
experiments  carried  out  last  summer  [1912]  have  convinced  me  that 
where  manure  is  not  taken  out  of  the  city  limits  promptly  the  best 
larvacide  is  Paris  green,  used  as  it  is  on  potato  plants,  about  one  ounce 
to  ten  gallons  of  water.  Where  this  is  conscientiously  sprinkled  on 
fresh  manure  the  larva  does  not  grow.  It  is  so  cheap  that  there  is  no 
excuse  on  that  point  for  not  using  it,  and  as  an  economic  proposition 
I  calculate  that  it  saves  about  one-third  of  the  fertilizing  value  of  the 
manure  from  being  destroyed  by  the  maggots."  (L.  M.  McCormick, 
Inspector.) 


NUISANCES  465 

to  see  that  it  ivS  being  properly  applied.  The  method  cer- 
tainly merits  attention  where  frccjuent  removal  is  imprac- 
ticable, as,  for  example,  in  rural  districts. 

In  this  connection  the  treatment  of  manure  in  specially 
constructed  maggot  traps  offers  considerable  possibilities, 
though  the  method  has  not  as  yet  been  entirely  worked  out.^ 

4.  Care  of  Refuse  other  than  Manure.  —  Since 
accumulations  of  garbage,  offal  and  the  like  are  not  usually 
.permitted  to  remain  as  long  as  those  of  stable  manure,  the 
amount  of  fly-breeding  due  to  them  is  comparatively  small. 
Such  refuse  should,  however,  be  kept  covered  and  should 
be  removed  regularly  at  frequent  intervals.  The  preven- 
tion of  obvious  nuisance  in  the  popular  sense  fortunately 
requires  this.  Markets  should  receive  special  attention  as 
regards  disposal  of  wastes.  Fly-breeding  may  readily  take 
place  in  garbage  dumps,  which  also  tend  to  support  a  popu- 
lation of  rats.  Such  dumps  should  be  prohibited  on  these 
specific  grounds  as  well  as  in  their  character  as  a  general 
public  nuisance. 

5.  Screening  of  privies,  sick-rooms,  kitchens  and  other 
rooms  in  dwelling  houses,  restaurants,  milk-rooms  and  the 
like  is  a  useful  means  of  guarding  against  flies  which  cannot 
practically  be  eliminated  by  the  foregoing  fundamental 
measures.  Citizens  may  be  advised  to  screen  dwelling 
houses  in  order  to  protect  foods,  baby's  bottle,  etc.  The 
screening  of  places  where  food  for  public  consumption  is 
handled  or  otherwise  exposed  may  be  required  by  ordinance. 
Cases  of  communicable  disease  may  be  required  to  be 
screened  and  the  flies  within  destroyed;  even  the  poorest 
families  can  usually  afford  mosquito  netting. 

The  most  important  measure  of  this  class  is  the  fly- 
proofing  of  privies  (see  under  Privies). 

1  Levy  and  Tuck,  "  The  Maggot  Trap  —  A  New  Weapon  in  Our 
Warfare  Against  the  Typhoid  Fly,"  Am.  Jour.  Pub.  Health,  1913, 
vol.  Ill,  no.  7,  p.  657;  Levy,  "  Modern  Methods  of  Fighting  the  House- 
fly," Am.  Jour.  Pub.  Health,  1914,  vol.  IV,  no.  5,  p.  439. 


466  A  MANUAL   FOR   HEALTH  OFFICERS 

,  The  health  officer  of  a  southern  city  where  privies  and 
flies  are  numerous  reports  as  follows: 

As  a  result,  I  believe,  of  the  screening  of  the  privies  and  sick  rooms, 
the  number  of  cases  of  typhoid  reported  to  the  Health  Department 
during  191 1  was  148  against  329  for  1910,  the  deaths  for  the  same 
years  being  40  against  62.  .  .  .  Not  only  did  this  reduction  occur,  but 
we  found  that  the  distribution  of  the  cases  as  to  privy  or  sewer  districts 
was  practically  reversed  in  191 1  from  that  of  1910,  showing  no  dis- 
proportion of  cases  in  the  privy  districts.' 

Even  if  only  a  part  of  the  above  improvement  were 
finally  proved  to  be  directly  due  to  screening,  it  would  still 
be  a  result  of  special  significance  to  communities  having 
the  unfortunate  combination  of  privies  and  flies. 

In  considering  the  use  and  value  of  screening  we  must 
bear  in  mind  the  various  circumstances  under  which  it  may 
be  applied.  In  urban  districts,  where  population  is  thick 
and  stables  and  other  possible  sources  of  flies  few,  the  fun- 
damental measure  of  f\y  elimination  should  certainly  be 
applied.  In  country  districts,  on  the  other  hand,  where 
breeding  may  go  on  to  a  greater  extent  and  is  relatively 
difficult  to  prevent,  the  fly-proofing  of  privies  and  the  use 
of  screens  for  milk-houses  and  dwellings  are  to  be  con- 
sidered as  a  possible  alternative. 

Popular  education,  as  to  the  manner  of  breeding  of  the 
fly  and  its  role  in  disease  conveyance,  is  a  useful  auxiliary 
measure,  but  cannot  take  the  place  of  vigorous  enforcement 
of  anti-fly  ordinances.  In  Asheville,  N.  C,  an  effective 
exhibit  illustrating  the  breeding  of  the  fly  is  used,  and  the 
inspectors  carry  small  specimens  showing  the  stages  of 
development  of  the  insect. 

Ordinances  should  be  adopted  covering  the  points  above 
mentioned    and    declaring    the    accumulation    of    manure, 

'  Terry  (Health  Officer,  Jacksonville,  Fla.),  "  Fly-borne  Typhoid 
and  Its  Control  in  Jacksonville,"  Southern  Med.  Jour.,  1913,  vol.  VI, 
no.  6,  p.  355. 


NUISANCES  467 

garbage  or  other  substance  in  which  fly  huva-  Ijrced  to  Ijc 
a  nuisance  subject  to  penalty  for  each  day  maintained. 
The  orders  adopted  by  the  District  of  Columbia  have  been 
justly  praised.^  It  is  desirable  to  require  licenses  for 
stables  in  order  to  impress  stable  proprietors  with  their 
responsibility  and  to  obtain  compliance  with  stable  and 
manure  regulations. 

Campaigns  for  the  destruction  of  flies  by  means  of  traps, 
"swatting,"  poisons,  fly  paper,  etc.,  are  more  remarkable 
for  spectacular! ty  than  for  efTficacy.  It  is  evident,  in  the 
first  place,  that  trapping  and  the  like,  even  when  most 
eflficient,  do  away  with  but  a  comparatively  small  propor- 
tion of  the  adult  fly  population,  particularly  if  it  is  being 
constantly  added  to  by  uncontrolled  breeding  places. 
Then,  when  it  is  considered  how  (as  already  explained)  a 
few  flies  are  capable  of  breeding  a  large  crop,  in  connection 
with  the  fact  that  many  flies  must  escape  trapping,  the 
futility  of  such  measures,  instead  of  the  prevention  of 
actual  breeding,  is  evident.  Fly  "swatting"  should,  there- 
fore, not  be  permitted  to  distract  attention  from  the  funda- 
mental problem. 

Traps  (preferably  of  the  large  size,  about  two  feet  high 
and  fifteen  inches  in  diameter  as  manufactured)  are  more 
useful  for  gauging  the  prevalence  of  flies  and  the  success  of 
anti-fly  measures  than  for  reduction  of  the  numbers  of  the 
insects.  Flies  caught  in  large  numbers  need  not  be  counted, 
but  may  be  measured  on  a  basis  of  13,000  to  the  quart. 

The  solution  of  the  problem  in  general  hinges,  in  towns, 
chiefly  upon  the  proper  construction  of  stables  and  the 
removal  or  treatment  of  stable  manure.  In  the  rural  dis- 
tricts, on  the  other  hand,  stables  may  be  poorly  constructed, 
the  manure  frequently  cannot  be  conveniently  removed  to 
a  distance,  it  is  difficult  or  impossible  to  compel  proper 
treatment  of  manure  and  frequent  inspections  perhaps 
cannot  well  be  made.  In  the  latter  case  the  fly-proofing  of 
'  Rosenau,  "  Preventive  Medicine  and  Hygiene,"  1913,  p.  231. 


468  A  MANUAL   FOR   HEALTH  OFFICERS 

privies  and  the  use  of  screens  may  perhaps  at  present  be 
relatively  more  practicable. 

REFERENCES 

U.  S.  Dept.  of  Agriculture,  Farmers'  Bulletins  459  (House  Flies) 
and  540  (The  Stable  Fly)  (apply  to  Supt.  of  Documents,  Washington, 
D.C.). 

Howard,  "  The  House  Fly  —  Disease  Carrier;  An  Account  of 
Its  Dangerous  Activities  and  the  Means  of  Destroying  It,"  Stokes  Co., 
New  York,  1912. 

Ross,  "  The  Reduction  of  Domestic  Flies,"  Lippincott,  Phila.,  1913. 

Hewitt,  "  House  Flies  and  How  They  Spread  Disease,"  19 12. 

Doane,  "  Insects  and  Disease." 

Rosenau,  "  Preventive  Medicine  and  Hygiene,"  1913,  p.  223  fF. 

Material  on  anti-fly  campaigns  is  published  by  the  American  Civic 
Assn.,  913  Union  Trust  Bldg.,  Washington,  D.  C. 

In  addition  to  papers  cited  see  Terr}',  "  Extermination  of  the  House 
Fly  in  Cities,  Its  Necessity  and  Possibility,"  Atn.  Jour.  Pub.  Health, 
1912,  vol.  II,  no.  I,  p.  14. 

11.   MOSQUITO  SUPPRESSION 

Nature  and  Control  of  Work.  —  The  mosquito  problem 
may  affect  public  health,  or  public  comfort,  or  both.  Where 
mosquito-borne  disease  —  malaria  or  yellow  fever  '  — 
exists  or  threatens,  mosquito  suppression  becomes  an 
obvious  duty  of  the  health  authorities;  in  communities 
where  these  diseases  do  not  exist  the  matter  is  simply  one 
of  public  comfort  and  property  values.  For  this  reason, 
and  because  thorough  work  in  mosquito-ridden  localities 
requires  extensive  operations  of  a  special  nature,  it  is  fre- 
quently desirable  that  the  work  be  performed  on  a  large 
scale  —  say  county-wide  —  by  special  authorities.^     When, 

1  For  discussion  of  the  relations  of  mosquitoes  to  these  diseases  see 
p.  207  ff . 

^  In  New  Jersey  long  experience  of  the  inability  or  unwillingness  of 
boards  of  health  to  cope  with  the  mosquito  problem  has  led  to  the 
establishment,  by  a  law  of  1912,  of  County  Mosquito  Extermination 
Commissions,  which  not  only  perform  inspections  but  also  carry  out 
much  of  the  work  —  such  as  elimination  of  marshes  —  necessary  to  a 
thorough  mosquito  reduction  campaign.     The  results  show  that  such 


NUISANCES  469 

however,  the  duty  rests  with  the  health  authorities  they 
should  if  possible  carry  it  out  thoroughly,  remembering, 
however,  that  sufficient  work  and  money  must  be  ap[)lied 
if  material  results  are  to  be  expected,  and  that  there  may 
be  other  public  health  demands  more  pressing. 

The  problem  of  mosquito  reduction  involves  far  more 
labor  and  expense  than  the  average  citizen  or  health  officer 
supposes.  For  adequate  inspection  the  ordinary  board  of 
health  staff  of  inspectors  must  practically  be  doubled,  and 
a  great  deal  of  extra  duty  is  thrown  upon  the  health  officer 
and  office.  Besides,  it  is  usually  necessary  to  employ 
special  labor  for  ditching,  etc.  Furthermore,  unless  the 
work  is  done  thoroughly,  very  little  result  may  be  evident 
and  the  work  will  be  discredited. 

The  Mosquito.  —  Besides  the  disease-bearing  species, 
there  are  others,  Culex  —  a  presumably  harmless  insect  — 
being  the  commonest.  All  mosquitoes  breed  in  standing 
water  and  nowhere  else  —  some  in  salt  and  some  in  fresh 
water.  The  malaria  and  yellow  fever  mosquitoes  breed 
only  in  fresh  water. 

The  life  history  of  the  mosquito  embraces  four  stages:  (i) 
^%%^  (2)  larva,  (3)  pupa  and  (4)  adult.  The  eggs  are  de- 
posited on  the  surface  of  stagnant  water,  particularly  that 
which  is  rich  in  organic  matter,  even  if  distinctly  foul.  The 
egg  hatches  out  into  a  larva  (or  "wiggler,"  such  as  is  fre- 

a  plan  might  well  be  adopted  wherever  a  great  amount  of  inspection 
and  labor  is  required.  The  work  may  thus  be  specialized  under  experts 
and  all  communities  derive  equal  benefit.  Under  the  plan  of  control 
by  local  boards  of  health  a  community  which  carries  on  an  effective 
campaign  may  still  suffer  from  the  inaction  of  its  neighbors.  (Infor- 
mation on  the  work  in  New  Jersey  may  be  obtained  from  the  State 
Entomologist,  New  Brunswick,  N.  J.) 

A  plan  for  giving  power  to  local  health  authorities  to  abate  breeding 
places  and  for  organizing  mosquito  reduction  work  on  a  state- wide  scale, 
under  the  Director  of  the  State  Experiment  Station,  has  been  proposed 
in  Connecticut.  (Report  on  Mosquito  Control,  Civic  Federation  of 
New  Haven,  1913  (Chamber  of  Commerce  Bldg.,  New  Haven,  Conn.) 


470  A  MANUAL   FOR   HEALTH   OFFICERS 

quently  seen  in  rain  barrels),  and  the  latter  into  the  shorter 
but  much  larger-headed  ])ui)a.  All  of  these  stages  are 
passed  in  the  water  and  linalK'  the  adult  mosquito  bursts 
from  the  pupa  and  Hies  a\va>-.  The  whole  cycle,  from  egg 
to  adult  insect,  takes  practically  from  nine  days  to  three 
weeks,  depending  upon  temperature  and  food  supplies. 
In  warm  weather  and  with  abundant  organic  matter  present, 
the  complete  development  will  take  place  in  a  minimum 
length  of  time. 

It  is  a  popular  belief  that  mosquitoes  breed  without 
water  in  grass,  bushes,  weeds  and  the  like.  This  is  un- 
true, for  a  continuous  existence  in  stagnant,  or  at  least 
standing,  water  is  necessary  for  development.  It  is,  how- 
ever, true  that  such  growths  shelter  the  adult  mosquitoes 
(which  die  if  exposed  to  the  sun  and  deprived  of  moisture), 
and  also  keep  them  from  being  carried  away  by  wind; 
hence  the  cutting  down  of  tall  grass,  weeds,  etc.,  assists  to 
that  extent. 

The  mosquito  survives  from  one  summer  season  to  the 
next  by  the  hibernation  of  a  few  insects  or  eggs.' 

Discrimination  may  easily  be  made  between  the  fresh- 
water mosquitoes  (e.g.,  Culex  pungens,  Anopheles  (malarial), 
A'edes  (yellow  fever))  and  the  salt-water  species  (of  which 
one  of  the  chief  is  the  Culex  sollicilans  of  the  Atlantic  Coast 
marshes).     The  latter  may  be  distinguished  by  thin  striped 

1  Many  mosquitoes  hibernate  in  the  cellars  or  basements  of  dwellings 
and  the  proposal  has  been  made  in  some  quarters  to  kill  all  such  mos- 
quitoes before  the  breeding  season  begins.  To  materially  reduce  the 
numbers  by  this  process  would  be  expensive  and  of  doubtful  value. 
The  labor  and  money  might  much  better  be  applied  to  abolition 
of  breeding  places  as  hereinafter  described.  For,  if  such  abolition 
be  effective  the  hibernated  mosquitoes  would  find  no  place  to  deposit 
eggs,  while  if  it  be  not  effective,  even  a  very  few  hibernated  mosquitoes 
(laying  several  hundred  eggs  apiece)  would  be  sufficient  to  start  a  big 
season's  crop. 

However,  for  the  purpose  of  killing  adult  mosquitoes  in  dwellings 
an  insecticide  may  be  used  —  e.g.,  sulphur,  pyrethrum  powder  or  Mim's 
culicide.     (See  pp.  588,  592.) 


NUISANCES  47  r 

legs  and  the  bar  across  the  proboscis  of  the  female,  as  well 
as  by  their  antipathy  to  entering  {iwelHhg  houses.  The 
Anopheles  (malarial)  mo.squito  may  be  recognized  by  its 
attitude  when  resting  or  biting,  in  which  the  body  and  pro- 
boscis form  an  acute  angle  with  the  surface  on  which  the 
insect  rests;  the  body  of  the  Culex,  on  the  contrary,  re- 
mains practically  parallel  with  the  resting  surface. 

Breeding-Places. — The  great  and  fundamental  means 
of  mosquito  reduction  is  the  elimination  of  accumulations 
of  stagnant  water,  even  in  small  quantities.  A  neglected 
tin  can  holding  water  may  breed  hundreds  of  mosquitoes 
during  a  season.  The  following  are  examples  of  the  breed- 
ing places  of  Culex  and  Anopheles  most  frequently  found 
in  practice: 

Swamps  and  marshes,  pools,  rain  puddles,  ditches,  puddles  of  standing 
water  along  watercourses,  the  margins  of  ponds,  etc. 

Brook  beds  (in  dry  weather). 

Cesspools  and  liquid  contents  of  privy  vaults. 

Vats  and  barrels  in  manufacturing  plants,  gardens  and  greenhouses. 

The  water  surrounding  commercial  gastanks,  etc. 

Sewer  catchbasins,  manhole  catchbuckets,  wells  (occasionally  in  hot 
weather),  rain  barrels,  cisterns,  tubs,  cans,  pails,  watering-pots  and  other 
receptacles  left  standing  so  as  to  harbor  water  (such  receptacles  are  ready 
breeders  unless  tightly  covered  or  screened). 

Various  places,  frequently  out-of-the-way,  such  as  the  crotches  of 
trees,  depressions  in  roof  gutters  and  the  like,  in  fact,  an^^  place  where 
water  may  stand  for  ten  days  or  more  in  warm  or  moderately  warm 
weather. 

The  breeding  habits  of  the  Aedes  (yellow  fever  mosquito) 
differ  from  those  of  the  above  genera.  The  breeding- 
places  of  Culex  and  Anopheles  are  much  more  widely  dis- 
tributed and  require  more  labor  to  detect  and  abolish  than 
those  of  Aedes,  which  is  practically  limited  to  artificial  con- 
tainers in  the  vicinity  of  human  habitations.  The  adult 
Aedes  also  tend  to  remain  comparatively  close  to  their 
birthplace. 

Administrative  measures  for  reduction  apply,  on  the  one 
hand,  to  the  large  marsh  areas,  where  engineering  skill  is 


47 :;  A  MANUAL  FOR   HEALTH  OFFICERS 

required  and  which  should  he  handled  by  state  or  county 
authoritN';  and,  on  the  other  hand,  to  the  numerous  breed- 
ing-places in  the  \icinity  of  dwellings  which  may,  if  need 
be,  be  dealt  with  by  local  inspections  and  action. 

I.  Permanent. — Whene\er  possible,  more  or  less 
permanent  measures,  even  if  high  in  first  cost,  should  be 
applied. 

First,  all  cisterns,  rain  barrels,  cesspools  and  other  con- 
tainers which  cannot  be  abolished  must  be  perfectly  cov- 
ered or  screened.  Care  must  be  taken  that  the  screen 
is  sufihciently  fine-meshed  (at  least  twenty  strands  to  the 
inch),  as  not  all  of  the  screens  on  the  market  are  perfectly 
mosquito-proof.  All  such  coverings  should  be  frequently 
reinspected  to  ensure  that  they  remain  perfectly  tight. 

The  best  way  to  treat  small  receptacles  is,  if  possible,  to 
break  or  pierce  them  so  that  they  cannot  act  as  containers 
of  water,  otherwise  to  turn  them  upside  down. 

Secondly,  swampy  land,  pools,  ditches  and  the  like 
should  be  drained  or  filled.  When  ditches  are  used  for 
draining,  they  must  be  cleaned  and  graded  from  time  to 
time.  Where  such  work  is  extensive,  it  is  just  that  this 
expense  be  defrayed  by  public  funds,  except  in  so  far  as  the 
value  of  the  property  is  increased. 

Ponds  and  pools  which  contain  fish  do  not  commonly 
breed  mosquitoes,  for  the  larva?  are  devoured  by  the  fish. 
Gold-fish  are  especially  effective  in  this  respect;  hence 
pools,  fountains  and  the  like  which  are  kept  for  decorative 
or  useful  purposes  may  be  kept  mosquito-free  by  stocking 
with  a  few  of  these  fish.  It  may  sometimes  be  more  feasible 
to  flood  a  swampy  area  and  introduce  fish  than  to  drain  or 
fill  it.  A  caution  is  required,  however,  in  relation  to  the 
borders  of  ponds,  where  mosquito  larva?  may  be  protected 
by  grass  and  weeds  and  in  pockets  and  puddles. 

Where  permanent  abatement  is  not  practicable,  oil 
may  be  applied  at  intervals  as  a  routine  measure  (see 
below). 


NUISANCES  473 

All  such  measures  require  systematic  inspections.  In 
towns  these  take  the  form  of  ijeriodic  house-to-house  in- 
spections, made  not  less  frecjuently  than  every  nine  or  ten 
days,  this  being  the  usual  minimum  breeding  period.  The 
inspector  should  himself  see  to  the  abatement  of  as  many 
breeding  "nests"  as  possible,  emptying  and  inverting  or 
puncturing  neglected  receptacles,  requiring  the  removal  or 
burial  of  old  cans  and  other  rubbish,  applying  oil  in  emer- 
gency, and  so  on.  In  instances  where  work  is  required  on 
the  part  of  property  owners  or  proprietors,  written  notice 
may  be  given.  Detailed  accounts  of  all  inspections  are  to 
be  kept,  and  the  areas  should  be  laid  out  in  such  a  way  that 
the  whole  district  may  be  covered  in  due  time. 

The  health  ordinances  should  contain  a  provision  making 
the  breeding  of  mosquitoes  a  nuisance  and  the  finding  of  the 
larva;  a  proof  of  the  fact;  such  nuisance  is  to  be  promptly 
dealt  with. 

Popular  educational  circulars  may  be  issued  with  the 
object  of  obtaining  public  support  and  aid  in  abating 
breeding.  Little,  however,  can  be  accomplished  by  volun- 
tary efifort  alone;  rigid  inspection  and  enforcement  of  law 
are  necessary. 

2.  Temporary.  —  As  a  temporary  measure,  as  well  as 
a  routine  measure  in  cases  where  permanent  abatement  is 
not  practicable,  the  application  of  oil  to  the  water  is  useful. 
The  oil  used  may  be  common  kerosene,  or  (better  because 
less  expensive  when  purchased  in  barrel  lots  or  more)  the 
partly  refined  petroleum  known  as  "fuel  oil"  —  price  about 
five  cents  per  gallon  in  quantities.  It  has  the  effect  of 
preventing  egg-laying  and  of  killing  at  once  any  larvae  or 
pupae  already  present  (through  clogging  the  air-tubes  when 
the  organisms  rise  to  the  surface  to  breathe).  A  pint  is 
sufficient  for  a  water  area  fifteen  or  twenty  feet  in  diameter. 
Care  must  be  taken  that  the  distribution  is  even,  that  small 
spaces  are  not  protected  from  the  spread  of  the  oil  film,  by 
sticks,  grass,  weeds  and  the  like,  that  wind  does  not  blow 


474  A  MANUAL   FOR   HEALTH  OFFICERS 

it  to  one  side,  etc.  A  spray  pump,  a  can  with  nozzle,  or  a 
mop  may  he  used  for  distribution.  Deft  scattering  by  means 
of  a  small  dipper  is  also  effective,  as  well  as  simple.  Owing 
to  evaporation,  wind  action,  etc.,  the  application  must  be 
repeated  at  intervals  of  ten  da>s  or  so,  depending  on  con- 
ditions.   Inspectors  should  note  such  places  on  their  rounds. 

In  brooks  ha\'ing  stagnant  spaces  along  the  banks  a  con- 
tinuous slow  application  may  be  effected  by  means  of  a 
drip  can;  this  consists  of  a  five-gallon  can  having  a  large 
wick  extending  front  the  bottom  up  through  the  opening 
in  the  top,  and  hanging  down  on  the  outside  to  a  length  an 
inch  or  two  below  the  bottom  of  the  can.  The  wick,  which 
acts  as  a  slow  siphon,  is  tied  secureh-  in  place  and  the  whole 
appliance  is  hung  under  a  bridge  or  tree  or  in  some  other 
secure  place  just  above  the  surface  of  the  water.  Such 
cans  of  course  require  periodic  renewal  of  oil. 

The  disadvantage  of  oiling  is  that  it  entails  continued 
labor  and  expense,  so  that  permanent  abatement  should  be 
secured  whenever  practicable. 

Screening,  etc.  —  If  the  above  measures  were  thoroughly 
carried  out  there  would  be  no  need  of  nettings  and  screens 
(unless  for  flies  and  other  insects)  and  the  use  of  citronella 
and  other  mosquito  repellents,  on  which  expedients  many 
thousands  of  dollars  are  spent  annually.  But  in  localities 
where  mosquito  suppression  is  non-existent  or  incomplete 
and  malaria  or  yellow  fever  mosquitoes  exist,  the  rigid 
screening  of  cases  of  these  diseases  and  of  dwellings  in 
general,  combined  with  the  capturing  ^  or  chemical  ex- 
termination (page  592)  of  mosquitoes  which  may  have 
gained  admittance,  constitute  a  very  valuable  protection. 

REFERENCES 
U.  S.  Dept.  of  Agriculture,  Farmers'  Bulletins  444  (Remedies  and 
Preventives   Against    Mosquitoes),   450    (Malaria),   and    547    (Yellow 
Fever  Mosquito)  (apply  to  Supt.  of  Documents,  Washington,  D.  C). 

1  See  Orenstein,  "  Mosquito  Catching  in  Dwellings  in  the  Pro- 
phylaxis of  Malaria,"  Am.  Jour.  Pub. Health,  1913,  vol.  Ill,  no.  2,  p.  106. 


NUISANCKS  475 

Doty,  "  The  Mosquito:  Its  Relation  to  Disease  aiifl  its  I'Lxtcrmina- 
tion,"  1912. 

Rosenau,  "  Preventive  Medicine  and  Hygiene,"  1913,  sec.  i,  chiip.  IV. 
Boyce,  "  Mos(|uito  or  Man  "  (relates  especially  to  the  Tropics). 
Doane,  "  Insects  and  Disease."  * 

See  also  references,  p.  209. 

The  roles  of  other  insects  and  vermin  (especially  rats)  in 
the  spread  of  disease  have  already  been  referred  to  (page 
210  f.).  The  use  of  certain  insecticides  is  also  referred  to 
in  Appendix  A.  Health  departments  do  not  undertake 
the  general  extermination  of  such  insects  and  vermin  un- 
less there  is  direct  or  threatened  danger  to  public  health. 


III.   MISCELLANEOUS  NUISANCES 

I.  Spitting.  —  Promiscuous  spitting  in  public  places 
should  be  prohibited  on  the  scores  both  of  disease  preven- 
tion and  of  decency.  While  the  danger  to  health  from  such 
spitting  has  doubtless  been  exaggerated  (relative,  for  ex- 
ample, to  other  more  direct  modes  of  the  spread  of  tuber- 
culosis), nevertheless  some  danger  probably  exists.  Such 
ordinances  usually  prohibit  spitting  upon  the  floor,  plat- 
form or  any  other  part  of  a  public  conveyance,  upon  the 
floor,  steps  or  stairs  of  any  public  building,  school,  hall, 
church,  store,  shop  or  railway  station,  upon  the  sidewalk  of 
any  public  or  private  street,  upon  the  pathway  of  any  park, 
or  in  any  other  public  place  (spitting  on  the  street  roadway 
and  gutter  excepted),  and  such  spitting  may  be  declared 
a  nuisance.  The  fine  should  be  comparatively  small,  say 
one  or  two  dollars,  so  that  arrests  and  convictions  may 
readily  be  secured,  and  the  police  should  be  empowered  to 
make  arrests  for  this  cause.  In  fact,  without  the  action 
of  the  police  little  can  be  done  by  the  sanitary  inspectors 
unless  they  have  the  power  of  arrest.  Small  cards  bearing 
a  copy  of  the  ordinance  and  a  brief  warning  to  be  handed  to 
offenders  by  patrolmen,  street-car  conductors  and  persons 


476  A  MANUAL   rOR   HEALTH  OFFICERS 

in  charge  of  public  jilaccs  are  useful.  Cuspidors  should  be 
provided  in  public  buildings  and  other  places  where  neces- 
sary. They  should  be  of  ample  size  and  of  paper  or  filled 
with  sawdust  so  that  the  contents  may  be  disposed  of  at 
frequent  intervals  by  burning.  If  the  contents  are  not 
thus  destructible  the  vessel  should  be  readily  cleansable 
and  should  be  partly  filled  with  a  disinfectant  solution. 

Under  ordinary  conditions  the  spitting  nuisance  appears 
to  be  less  a  matter  of  health  than  of  decency. 

2.  Smoke,  Dust,  Gases,  Obnoxious  Trades.  —  Under 
this  head  we  shall  consider  various  aerial  nuisances  which 
have  a  decided  bearing  on  comfort  and  more  or  less  bear- 
ing on  health,  especially  on  the  health  of  persons  living 
near  industrial  plants  or  working  in  certain  trades.  In  a 
general  consideration  of  the  smoke  and  dust  nuisances  there 
are,  furthermore,  economic  waste  and  damage  to  be  taken 
into  account.  Smoke  and  soot  may  also  damage  vegeta- 
tion. Health  authorities  have  on  the  whole  less  control 
over  nuisances  of  this  class  than  over  those  previously 
mentioned,  for  the  reason  that  proving  injury  to  health  is 
not  infrequently  difficult.  In  many  cases  it  is  necessary 
to  have  specific  statutory  power  granted. 

The  Smoke  Nuisance  has  been  taken  up  by  a  number  of 
cities  and  is  being  dealt  with  with  increasing  success  as 
improved  furnace  design,  mechanical  stokers  and  methods 
of  stoking  are  adopted  in  power  houses  and  factories. 
The  nuisance  is  greatest  where  soft  coal  is  used.  Unfor- 
tunately the  data  on  the  direct  effect  of  smoke  pollution 
on  health  are  meagre.  It  seems  clear,  however,  that 
deleterious  efTects  —  in  some  cases  very  considerable  — 
must  result.^ 

1  See  White  and  Marcy,  "  A  Study  of  the  Influence  of  Varying 
Densities  of  City  Smoke  on  the  Mortality  from  Pneumonia  and  Tu- 
berculosis," Trans.  XV  Internal.  Congress  Hyg.  and  Demogr.,  1912, 
vol.  Ill,  pt.  II,  p.  1020;  Benner,  "  How  and  Why  Smoke  is  Injurious," 
ibid.,  p.  1015;  Klotz,  "Pulmonary  Anthracosis  —  A  Community 
Disease,"  Am.  Jour.  Pub.  Health,  1914,  vol.  IV,  no.  10,  p.  887. 


NUISANCES  477 

The  discharj^c  of  "dense  smoke"  (from  factories,  f)ower 
plants,  automobiles,  locomotives,  etc.)  is  prohibited  in  a 
considerable  number  of  cities;  the  experience  of  the  New 
York  City  Health  Department  may  be  cited  as  indicative 
of  what  may  be  accomplished  in  this  direction.  The  Ameri- 
can Civic  Association  has  collected  valuable  data  on  the 
matter.^ 

The  Dust  Nuisance  is  another  of  this  class.  While  it  is 
generally  accepted  by  sanitarians  that  the  part  played  by 
ordinary  dust  in  the  transmission  of  disease  is  (as  compared 
with  other  influences  and  modes  of  infection)  a  minor  one,^ 
there  are  nevertheless  certain  circumstances  under  which 
dust  may  possibly  convey  infection  (e.g.,  mouth  strep- 
tococci and  tubercle  bacilli)  or  so  wound  the  delicate  linings 
of  the  respiratory  passages  as  to  give  infection  a  foothold. 
Hence  it  may  be  that  many  of  the  respiratory  diseases  in 
windy,  dusty  towns  are  thus  directly  or  indirectly  caused. 
While  it  must  not  be  supposed  that  ordinary  dust  ranks  in 
the  same  class  as  contact  and  food  infection  in  disease  causa- 
tion (since,  for  one  thing,  bacteria  tend  to  die  out  rapidly 
in  dry,  sun-exposed  material),  there  is  sufficient  reason  to 
consider  the  dust  nuisance  as  one  more  or  less  prejudicial 
to  health.^  Also,  of  course,  the  consideration  of  public 
comfort  enters  into  a  large  extent. 

The  suppression  of  outdoor  dust  has  scarcely  been  touched 
upon  by  public  regulations,  though  with  the  increasing  use 

1  "  The  Smoke  Nuisance  "  (pamphlet,  25  cents),  Am.  Civic  Assn., 
913  Union  Trust  Bldg.,  Washington,  D.  C.  A  number  of  publications 
on  the  subject  may  also  be  obtained  from  the  American  City  Bureau, 
93  Nassau  St.,  New  York  City. 

2  The  statement  made  by  Prudden  in  his  monograph  on  "  Dust  and 
Its  Dangers,"  written  in  1890,  still  apparently  holds  good:  "  On  the 
whole,  the  risk  of  infection  out-of-doors  from  dust,  even  in  crowded 
towns,  unless  thej'  are  notably  filthy,  is  not  actually  ver^-  great." 

'  See  Winslow  and  Kligler,  "  A  Quantitative  Study  of  the  Bacteria 
in  City  Dust  with  Special  Reference  to  Intestinal  and  Buccal  Forms," 
Am.  Jour.  Pub.  Health,  1912,  vol.  II,  no.  9,  p.  663. 


478  A  MANUAL   FOR   HEALTH   OFFICERS 

of  motor  vehicles  and  heavier  traffic  it  becomes  constantly 
more  important,  as  affecting  comfort,  health  and  property. 
It  is  largely  a  matter  of  municipal  cleanliness  and  highway 
engineering,  properly  to  be  dealt  with  by  municipal  street 
departments. 

Certain  kinds  of  indoor  dust,  on  the  other  hand,  constitute 
a  very  serious  health  problem,  as,  for  example,  in  the  "dusty 
trades"  (Chap.  V).  In  private  houses  and  in  institutions 
the  employment  of  dry  dusting,  sweeping,  indoor  beating  of 
carpets,  etc.,  should  be  discouraged  by  educational  measures 
as  being  more  or  less  detrimental  to  health.  The  damp  or 
dustless  duster  should  be  substituted  for  the  feather  duster. 
The  carpet  sweeper,  vacuum  cleaner  or  at  least  damp 
sweeping  should  replace  the  ordinary  dry  use  of  the  broom. 

Gases  —  Obnoxious  Trades.  —  Nuisances  due  to  es- 
cape of  deleterious  gases  may  be  dealt  with  under  the 
general  power  to  forbid  pollution  of  the  atmosphere.  In 
many  such  instances,  however,  it  is  much  more  difficult 
to  prove  detriment  to  health  than  interference  with  com- 
fort. The  same  is  true  of  the  so-called  "noxious  trades" 
(better  called  "obnoxious")  which  are  often  unpleasant  to 
neighbors  but  which,  for  the  welfare  of  society,  must  be 
carried  on  somewhere.  Such  trades  are  tanning,  manu- 
facturing fertilizer,  garbage  reduction  and  the  like.  Such 
should  be  required  to  be  conducted  in  the  least  possible 
objectionable  manner  and  may  perhaps  be  restricted  to 
certain  distances  from  neighboring  habitations. 

Aside  from  special  local  atmospheric  pollutions,  there 
is  likely  to  be  more  or  less  illuminating  gas  in  the  air  of 
cities,  due  to  leaks  in  gas  mains  and  piping.  If  this  is 
excessive  it  may,  as  shown  in  Chapter  V,  be  a  distinct 
detriment  to  health. 

3.  Noise.  —  Excessive  noise  has  long  been  recognized  as 
a  nuisance  affecting  comfort,  but  only  recently  has  scientific 
attention  been  directed  to  it  as  a  detriment  to  health. 
Even  as  yet  (as  is  the  case  with  many  of  the  nuisances  of 


NUISANCES  479 

class  III)  there  is  little  direct  evidence  as  to  its  effects  on  the 
human  organism,  although  there  is  no  question  in  experience 
that  such  effects  result  in  losses  in  health,  comfort  and 
efficiency,  which,  in  the  case  of  many  persons  of  sensitive 
nervous  temperament,  may  be  very  considcrahle.  With  the 
increase  of  noise  in  cities  and  in  the  neighborhood  of  indus- 
trial plants  and  with  the  increased  strains  placed  on  the 
nervous  system  by  modern  life  in  many  directions,  there  is 
developing  a  movement  for  the  suppression  of  unnecessary 
noise.  The  difficulty  will  be  to  determine  which  noises, 
out  of  those  incidental  to  life  in  modern  communities,  are 
unnecessarily  detrimental  to  public  health  and  comfort. 
In  many  legal  decisions  on  record,  the  courts  have  expressed 
themselves  as  perplexed  over  questions  on  this  point. 
Health  authorities  have  not  gone  very  far  in  noise  suppres- 
sion, and  most  of  the  decisions  have  been  under  police 
actions  or  suits  by  private  persons  for  indictments  or 
damages  for  disturbance  of  comfort  or  of  use  of  property. 
Already  "zones  of  quiet"  for  the  protection  of  hospitals 
are  established  in  some  cities,  and  the  movement  for  general 
restriction  of  noise,  under  control  of  either  police  or  health 
authorities,  should  continue  to  develop.^  Such  movements 
indicate  the  increasing  attention  being  paid  to  the  protec- 
tion of  the  senses  in  modern  life. 

^  See  Blake,  "  The  Suppression  of  Unnecessary  Noise,"  Trans.  XV 
Internal.  Congress  on  Hyg.  and  Demogr.,  1912,  vol.  Ill,  pt.  II,  p.  533; 
and  Bell,  "  Existing  Legal  Provisions  with  Regard  to  the  Suppression 
of  Unnecessary  Noises,"  ibid.,  p.  536.  A  number  of  publications  on  the 
subject  may  be  obtained  from  the  American  City  Bureau,  93  Nassau 
St.,  New  York  City. 


CHAPTER   VII 

SANITARY  LAW 

The  general  status  and  powers  of  health  authorities  have 
already  been  outlined  in  Part  I,  Chapter  I.  We  shall  add 
here  only  a  few  remarks  on  the  making  and  enforcing  of 
ordinances. 

Laws  and  Ordinances.  —  Under  the  police  powers 
assigned  to  local  health  authorities  by  state  legislatures  — 
which  powers  are  defined  by  the  statutes  in  general  rather 
than  in  specific  and  detailed  terms  —  it  is  necessary  that 
such  authorities  exercise  a  quasi-legislative  function  in  pass- 
ing ordinances  to  meet  local  conditions.  Such  ordinances 
should  be  framed  by  the  legal  counsel  of  the  board  of  health, 
on  the  basis  of  data  submitted  by  the  health  officer,  so  as 
to  be  in  conformity  with  legal  powers  as  well  as  sanitary 
requirements.  Further,  the  law  frequently  provides  for 
the  just  right  of  citizens  to  be  heard  on  an  ordinance  pending 
passage  and  for  the  advertising  of  ordinances  proposed  or 
adopted,  prescribing  the  procedure  to  be  followed. 

Without  going  into  technical  legal  points,  it  is  well  that 
health  authorities  should  recognize  the  following  principles 
in  the  adoption  of  regulations.^ 

(i)  The  condition  which  is  sought  to  he  met  must  he  suffi- 
ciently important  to  warrant  the  remedy  proposed.  In  other 
words,  the  public  health  must  be  materially  and  demonstra- 
bly affected  and  the  benefits  to  be  gained  from  the  remedy 
greater  than  its  expense  and  inconvenience. 

(2)  The  remedy  proposed  must  he  reasonahly  adequate. 
It  is  proper,  however,  since  perfect  control  and  regulation 

*  Evans,  W.  A.,  "  Legal  Powers  of  Health  Departments,"  The 
American  City,  Aug.,  1912,  p.  121. 

4S0 


SANI'IARY    LAW  481 

can  in  practice  be  gained  only  by  stages,  to  establish  ad- 
vancing standards,  that  is,  to  proceed  from  moderately 
stringent  to  more  stringent  ordinances.  In  cases  where  a 
very  radical  set  of  regulations  would  be  impossible  to  enact 
and  enforce,  the  control  may  be  gained  by  steadily  raising 
the  requirements  from  time  to  time.  Ordinances  may  be 
adopted  providing  for  the  application  of  certain  regulations 
after  a  certain  date  or  permitting  one  standard  for  future 
installations  or  performances  and  another  for  present  or 
past.  Thus  the  theoretical  principle  of  perfect  adequacy 
is  compromised  by  practical  considerations,  the  highest 
standards  enactable  and  enforceable  at  the  time  being 
adopted  in  progression.  But,  on  the  other  hand,  under 
propitious  conditions  —  e.g.,  a  new  administration  or  favor- 
able public  sentiment  —  it  may  be  possible  to  put  through 
sweeping  changes. 

If  ordinances  are  reasonable,  as  above  implied,  they 
will  not  work  undue  hardships  on  the  property  and  rights 
of  individuals.  Very  stringent  regulations  working  serious 
hardship  may,  however,  be  necessary  when  a  grave  con- 
sideration of  public  health  is  at  stake.  Health  authorities 
must,  of  course,  be  prepared  to  justify  such  regulations. 

Legal  Remedies.  —  The  sanitary  law  affords  several 
different  kinds  of  remedies  (some  of  which  have  been  men- 
tioned in  the  last  chapter)  under  both  civil  and  criminal 
procedure,  by  private  and  by  public  action.  These  include 
suit  for  damages  and  lines,  injunction,  etc.  The  procedure 
commonly  adopted  by  health  authorities  is  that  of  suit  for 
collection  of  the  penalty  or  penalties  for  a  statute  or  health 
ordinance  which  has  been  violated.  On  filing  of  a  com- 
plaint in  proper  form  the  court  issues  against  the  defendant 
a  warrant  (for  arrest)  or  summons  (for  appearance),  as  the 
case  may  require,  usually  the  latter. 

An  important  and  necessary  part  of  every  ordinance  is 
the  penalty  clause,  without  which  it  is  impotent.  In  this 
connection  it  may  be  observed  that,  while  very  heavy 


482  A  MANUAL   FOR  HEALTH  OFFICERS 

penalties  are  impressive,  there  is  likely  to  be  hesitancy  in 
their  enforcement;  the  penalty  should  be  adapted  to  the 
importance  of  the  offense  and  should  be  greater  for  second 
and  subsequent  offenses.  In  the  case  of  nuisances  and 
other  continued  conditions  each  day  should  constitute  a 
separate  offense.  Statutes  may  provide,  for  cases  in  which 
the  fine  is  not  promptly  paid,  the  further  measure  of  im- 
prisonment. In  some  instances  costs  of  nuisance  abate- 
ment, etc.,  may  become  a  lien  on  the  property  of  the 
offender. 

Enforcement.  —  No  matter  how  much  willing  co5pera- 
tion  is  obtained  by  the  health  department  there  will  always 
remain  a  certain  number  of  instances  in  which  compliance 
with  the  law  can  be  obtained  only  by  prosecution.  As 
soon  as  such  cases  are  recognized  by  the  authorities  they 
are  bound  to  take  legal  action  without  fear  or  favor. 

There  is,  however,  one  preliminary  to  be  disposed  of. 
Although  there  is  a  legal  maxim  that  "ignorance  of  the  law 
is  no  excuse  for  its  breach,"  it  is  nevertheless  an  accepted 
principle  that  the  person  responsible  for  a  condition  or  act 
contrary  to  public  health  law  receive  due  written  notice  in 
order  that  he  may  have  the  opportunity  to  adjust  himself 
and  his  property  to  the  requirements  of  the  law.  This  is 
only  reasonable,  since  most  persons  are  unacquainted  with 
the  more  detailed  and  technical  requirements.  The  giving 
of  such  notice  and  its  form  and  manner  are  usually  provided 
for  in  the  law  itself.  This  has  in  some  instances  been 
carried  to  extremes  of  formality.  Notices  need  only  be  so 
worded,  in  accordance  with  the  terms  of  the  ordinance,  as 
to  be  clear  to  a  man  of  average  intelligence.  The  neces- 
sary blank  forms  for  notices  should  be  drawn  up  under 
legal  advice;  then  only  the  particulars  need  be  filled  in  for 
each  case.  The  notice  is  then  served  strictly  in  the  manner 
required  by  law. 

In  all  cases  care  should  be  taken  to  notify  and,  if  neces- 
sary,  prosecute,    the   person   who   is  actually   responsible 


SANITARY  LAW  483 

rather  than  an  employee  or  agent,  though  the  lalt(-r  is 
sometimes  the  only  one  who  can  be  reached.  Thus,  in 
prosecutions  under  ordinances  governing  milk  supi;Hes,  the 
person  or  firm  under  whose  care  improper  handhng  or  adul- 
teration takes  place,  wholesaler  or  retailer,  should  be  the 
object.  But  if  it  is  found  that  the  wholesaler  or  farmer  is 
at  fault  and  cannot  be  reached  by  local  prosecution,  the 
retailer  of  the  supply  should  be  given  notice  so  that  he  may 
change  his  supply  and  thus  avoid  prosecution. 

The  following  points  in  regard  to  prosecutions  are  wortli 
noting: 

(i)  The  evidence  upon  which  a  case  is  to  be  based  must 
be  adequate  and  reliable.  Recourse  should  not  be  had  to  a 
court  of  law  without  a  reasonable  certainty  that  sufificient 
proof  can  be  offered.  Witnesses  must  be  reliable  and  testify 
of  their  own  direct  knowledge  regardless  of  hearsay,  which 
is  of  course  worthless  as  evidence. 

(2)  The  authorities  should  be  prepared  and  determined 
to  pnsh  every  case  through  to  its  logical  conclusion.  Appeal 
to  higher  courts  should  be  taken  if  necessary  and  the  case 
is  one  in  which  success  is  reasonably  to  be  expected.  Very 
frequently  after  a  case  has  been  started  the  defendant  will 
at  once  take  steps  to  comply  with  the  law,  and  this  may  be 
argued  as  a  reason  for  discontinuing  the  suit  when  com- 
pliance is  seen  to  be  secured.  But  as  a  general  rule  judg- 
ment should  be  secured  and  the  penalty  should  be  exacted 
as  a  deterrent  from  future  offences  and  in  order  parti}'  to 
repay  the  health  department  for  the  time  put  into  the  case. 
The  authorities  who  gain  a  reputation  for  fighting  to  the 
end  will  find  their  work  much  facilitated,  while  a  reputation 
for  leniency  can  only  have  the  opposite  effect  and  lead  to 
disrespect  for  the  law. 

(3)  The  publicity  given  to  prosecutions  is  a  valuable 
assistance  in  securing  compliance  with  law. 

(4)  Laivs  should  be  enforced  uniformly  and  prosecutions 
should  not  be  withheld  on  account  of  the  personal  influence 


484  A  MANUAL  FOR  HEALTH  OFFICERS 

or  reasons.  Such  a  policy  is  not  onl>-  unjust,  but  in  the 
long  run  leads  to  disrespect  of,  and  resentment  against,  the 
law. 

Tendencies  in  Sanitary  Legislation.  —  Several  note- 
worthy tendencies  are  to  be  seen  in  public  health  legislation 
today.  One  of  these  is  the  increasing  importance  of  specific 
statute  law  defining  the  powers  and  duties  of  health  authori- 
ties. This  is  in  line  with  the  growth  of  definite  scientific 
knowledge  of  methods  of  prevention.  So  long  as  legal 
powers  are  vague  and  overgeneral,  action  is  uncertain,  but 
specific  law  both  permits  and  requires  effective  action. 
Health  reforms  clearly  needed  should  be  crystallized  in 
such  law. 

Along  with  this  there  is  the  movement  to  require  expert 
service  and  to  entrust  technical  questions  to  those  qualified 
to  deal  with  them. 

Again,  while  in  the  past  there  has  been  perhaps  an  undue 
emphasis  on  the  vested  rights  of  individuals  and  corpora- 
tions, it  is  now  the  tendency  to  enact  thorough  socially 
constructive  laws  by  which  those  rights,  while  duly  re- 
spected, are  subordinated  when  public  health  is  at  stake. 
At  the  same  time  damages  to  the  private  individual  through 
public  conditions  over  which  he  has  no  control  are  coming 
into  a  status  as  subjects  for  compensation.  Thus  it  is 
possible,  according  to  at  least  one  important  decision  * 
for  the  individual  to  recover  damages  for  sickness  caused 
by  a  polluted  public  water  supply.  Again  under  work- 
men's compensation  acts  the  purity  of  water  supplied  by 
employers  (as  well  as  other  sanitary  matters)  may  come  into 
question. 

In  general,  a  reform  of  public  health  laws  to  harmonize 
with  modern  sanitary  science  is  needed.  This  would  result 
in  a  correct  perspective  and  in  considerable  clarification 
through  the  elimination  of  obsolete  sections  of  the  law. 
The  new  public  health  law  and  regulations  recently  adopted 
1  See  note,  p.  413. 


SANITARY    I. AW  485 

in  New  York  State  is  an  example  of  such  reform.  f)n  the 
other  hand,  a  uniformity  which  would  stifle  develojiment 
of  procedure  is  to  be  avoided. 

Finally,  it  must  be  remembered  that,  under  a  democratic 
system,  consent  to  the  adoption  of  laws  depends  ultimately 
upon  public  sentiment,  which  should  be  gradually  moulded 
to  sanction  the  standards  needed. 

REFERENCES 

Among  the  legal  works  dealing  with  public  health  are  the  following: 

Parker  and  Worthington,  "  The  Law  of  Public  Health  and  Safety," 
1892. 

Joyce,  "  The  Law  of  Nuisances,"  1906. 

As  an  example  of  a  manual  on  local  state  law  (New  York  State)  may 
be  cited  Bender's  "  Health  Officers'  Manual  "  (Bender  and  Co.,  Al- 
bany, N.  Y.). 

Cf.  papers  by  Ball  and  Hemenway  in  Jour.  Am.  Pub.  Health  Assn., 
191 1,  nos.  2,  4,  on  powers  of  health  authorities. 


CHAPTER   VIII 
THE  ANNUAL   REPORT 

Value  and  Use  of  Annual  Report.  —  One  of  the  major 
duties  of  the  health  department  is  to  publish  a  good  an- 
nual report.  For  communities  of  the  smaller  size  such 
report  need  not  necessarily  be  lengthy  or  expensive,  but 
should  cover  all  the  essential  points.  The  importance  of 
the  annual  report  has  not  been  sufficiently  recognized;  by 
too  many  health  officers  and  boards  it  is  regarded  as  a 
perfunctory  extra  labor  to  be  put  off  to  the  latest  possible 
time  or  even  to  be  omitted  entirely.  Needless  to  say  this 
attitude  is  a  mistake.  The  annual  report  is  the  necessary 
accounting  of  the  health  officer  to  the  board  for  the  work 
of  the  year;  it  is  the  accounting  of  the  health  department 
to  citizens  and  municipal  government  for  the  funds  ap- 
propriated; it  is  to  the  health  officer  himself  an  indis- 
pensable review  of  the  year's  work  and  a  basis  for  laying 
plans  for  the  future  and  making  recommendations;  and 
if  it  sets  forth  administrative  progress  as  it  should  it  is 
of  comparative  interest  and  value  to  health  departments 
of  other  communities.  It  should  also  embody  matter  of 
popular  information  and  use,  as  when  the  names  of  milk 
dealers  are  published  in  the  order  of  their  standings. 
Since  the  results  of  public  health  work  are  not  evident  to 
the  public  eye  as  those  of  some  of  the  other  departments 
of  municipal  activity,  it  is  all  the  more  important  that  they 
should  be  set  forth  as  tangible  facts. 

If  proper  weekly  and  monthly  (and  even  daily)  reports 
of  health  officers  and  inspectors  are  kept,  the  composition 
of  the  annual  report  should  not  be  an  excessive  task.     The 


TFIK    ANNUM.    RKI'CmT  487 

health  officer  should  present  monthly  a  written  rcpc^rt  to 
his  board  summarizing  the  work  performed  by  him  and 
under  his  direction,  and  these  monthly  reports  will  assist 
greatly  in  making  up  the  annual  report.  The  facilitation 
of  reporting  is  indeed  one  of  the  chief  advantages  of  a 
good  recording  and  filing  system;  but  on  the  other  hand, 
if  work  is  performed  without  Qonstant  record  being  kept 
it  is  impossible  to  make  it  appear  and  obtain  credit  for  it. 

For  the  maximum  value  of  an  annual  report  two  things 
are  necessary:  that  it  should  be  in  proper  form  and  in- 
clusive of  all  essential  points,  and  that  it  should  be  issued 
with  reasonable  promptness.  Care  should  be  taken  that  it 
is  in  the  hands  of  the  municipal  authorities  at  the  time 
when  appropriations  are  made.  In  any  case  a  report  pub- 
lished long  after  the  close  of  the  year  has  lost  a  great  deal 
of  its  interest  and  value. 

Standard  Plans  for  Reports.  —  Owing  to  the  lack  of 
uniformity  in  essentials  in  local  health  reports,  the  formu- 
lation of  standard  plans  for  the  assistance  of  the  health 
officer  has  been  undertaken  in  at  least  two  states  (Massa- 
chusetts and  New  Jersey)  by  committees  between  which 
there  was  some  conference.  The  plan  adopted  by  the 
Health  Officers'  Association  of  New  Jersey  is  reprinted  in 
the  present  volume  {Appendix  G).  That  of  the  Massa- 
chusetts Association  of  Boards  of  Health  has  already  been 
published  elsewhere.^ 

The  use  of  such  a  plan  should  not  discourage  initiative 
and  individuality  of  treatment,  for  it  applies  only  to  the 
fundamentals  which  should  be  covered  by  any  health 
report. 

A  consideration  of  the  published  health  reports  of  the 
better  class  is  recommended.  Among  small  cities  which 
issue  full  and  effective  reports  may  be  mentioned  Mont- 
clair.  Orange,  and  Plainfield,  N.  J.,  Brockton,  Mass.,  and 
Palo  Alto,  Cal.  In  Montclair  an  approach  is  being 
^  See  note,  p.  621. 


488  A  MANUAL  FOR   HEALTH  OFFICERS 

made  toward  the  presentation  of  unit  costs  for  the  various 
items  of  health  work.  Among  reports  issued  by  the  larger 
cities  those  of  Providence,  R.  I.,  Richmond,  Va.,  and 
Jacksonville,  Fla.,  merit  special  mention  for  analysis  of 
administrative  problems  and  interpretation  of  vital 
statistics. 

Distribution.  —  The  annual  report  should  be  distrib- 
uted by  mail  or  by  direct  hand  distribution  to  city  officials, 
physicians,  the  more  prominent  citizens,  ministers,  milk 
dealers,  and  others  who  would  be  directly  interested.  A 
certain  number  should  also  be  sent,  as  "exchanges,"  to 
other  health  departments,  particularly  those  of  places  of 
about  the  same  size  and  those  in  the  same  state.  The 
reprinting  of  certain  portions  of  the  report  and  its  dis- 
tribution as  a  popular  bulletin  will  be  mentioned  in  Chap- 
ter X  (page  553). 

Press  Notice.  —  It  is  important  that  arrangements  be 
made  for  a  good  press  notice  in  connection  with  the  re- 
port. Local  newspapers  should  be  furnished  several  days 
beforehand  with  copies  of  the  report  which  the  health 
officer  intends  to  read  to  his  board,  or  at  least  of  the  more 
important  portions  of  it;  which  may  be  thus  printed  at 
some  length  as  soon  as  the  reading  has  taken  place.  Such 
publicity  is  very  valuable  and  the  press  will  appreciate  the 
opportunity  to  print  and  perhaps  support  by  editorial 
comment  the  annual  message  thus  delivered  by  the  health 
officer. 


CHAPTER   IX 
VITAL  STATISTICS 

Vital  statistics,  according  to  Ncwsholmc,  is  the  science 
of  numbers  applied  to  the  life  history  of  communities  and 
nations;  Wilbur  calls  it  the  Cinderella  of  modern  public 
hygiene,  sitting  in  the  chimney  corner  sifting  the  ashes  of 
dusty  figures  while  the  proud  sisters,  bacteriology  and  pre- 
ventive medicine,  go  to  the  ball  and  talk  about  the  wonder- 
ful things  they  have  done;  a  third  statistician,  Guilfoy, 
defines  it  more  precisely  as  "the  numerical  registration  and 
tabulation  of  population,  marriages,  births,  diseases,^  and 
deaths,  coupled  with  analyses  of  the  resulting  numerical 
phenomena  with  the  end  in  view  of  'searchlighting'  the 
path  of  sanitary  progress."  ^ 

Vital  Statistics  are  the  Indispensable  Basis  of  Public 
Health  Work.  —  This  is  a  fact  not  sufBciently  recognized 
among  health  officers,  who  not  infrequently  regard  the 
annual  report  with  its  necessary  tabulations  as  formal 
rather  than  useful.  On  the  contrary,  public  health  work 
can  no  more  be  directed  intelligently  without  statistics 
than  can  a  business  be  conducted  without  figures  for  in- 
come and  expenditure,  profit  and  loss.  Instead  of  being 
regarded  as  mere  formality  and  history,  vital  statistics 
should  be  the  constant  basis  of  public  health  work.  If 
certain  tabulations  are  kept  up  from  week  to  week  and 
from  month  to  month,  the  health  officer  will  always  have 

1  The  term  "vital  statistics"  is  not  alwaj's  taken  to  include  statistics 
of  disease  (morbidity  statistics).  —  J.  S.  M. 

"^  Guilfoy,  W.  H.,  "Vital  Statistics  in  the  Promotion  of  Public 
Health,"  New  York  Medical  Journal,  November  5,  1910,  and  Jour. 
Atti.  Pub.  Health  Assti.,  191 1,  vol.  I,  p.  486. 

489 


490  A  MANUAL   FOR  HEALTH  OFFICERS 

ihe  main  data  in  mind  and  the  dreaded  composition  of  the 
annual  report  will  be  much  facilitated.  This  will  also 
make  for  promptitude,  for  statistics  should  be  fresh  — 
tabulated  as  soon  as  data  are  complete.  Those  published 
months  later  have  lost  bolli  in  inierest  and  \irtue. 

Practically,  the  value  of  \ital  statistics  may  be  seen. 
Thus  Abbott,  writing  some  years  ago,  said  that  "Those 
states  which  have  made  the  most  commendable  progress 
in  preventive  medicine  are  also  the  states  which  have 
brought  their  systems  of  registration  to  the  highest  de- 
gree of  perfection." 

The  processes  of  vital  statistics  are  frequently  thought  to 
be  highly  technical  and  mathematical.  It  is  true  that  the 
"theory  of  statistics"  is  a  mathematical  subject  and  one 
which  easily  runs  into  abstruseness  in  its  advanced  aspects. 
But  the  health  ofificer  need  not  be  discouraged,  for  the  com- 
paratively little  theory  wh-ich  he  needs  to  know  is  simple, 
though  he  needs  to  know  this  little  very  thoroughly. 
The  former  Chief  Vital  Statistician  of  the  U.  S.  Census, 
Dr.  Wilbur,  tells  us  that  "«o  great  degree  of  mathematical 
attainment  is  necessary  for  some  of  the  most  important  practi- 
cal applications  of  vital  statistics.  The  ordinary  ratios  or 
'rates'  employed  in  vital  statistics  are  as  easily  com- 
puted and  understood  as  the  'percentages'  so  familiar  to 
the  baseball  public."  The  necessary  knowledge  of  vital 
statistics  and  its  processes  is,  therefore,  well  within  the  reach 
of  the  health  officer. 
Says  Whipple: 

Vital  bookkeeping  is  carried  on  much  as  ordinary  bookkeeping. 
There  are  daily  entries  of  accessions  and  losses  as  they  occur,  corre- 
sponding to  receipts  and  payments;  there  are  weekly  statements,  monthly 
statements,  and  annual  statements;  and  at  longer  intervals  there  is  a 
taking  account  of  stock,  that  is,  a  census.  This  difference,  however, 
should  be  noted.  Accounts  are  accurate  records  of  transactions  and  if 
properly  kept  an  exact  balance  will  be  obtained.  Vital  statistics  are 
not  always  accurate.  The  individual  data  are  incomplete  and  sub- 
ject to  error.     The  results,  therefore,  lack  the  precision  of  monetary 


VrrAF>   STA'PFSTICS  49  f 

accounts.     It  is  necessary  to  keep  this  fact  constantly  in  minrj  when 
interpreting  the  results  of  statistical  studies.' 

Vital  statistics,  to  be  of  benefit  to  the  community,  must 
be  used,  says  Whipple,  "with  truth,  with  imagination,  and 
with  power."  They  must  be  accurate,  their  application 
to  the  situation  must  be  brought  out,  and  they  must  be 
brought  home  forcefully  to  the  people  and  those  responsible 
for  the  care  of  the  pul)lic  health.  A  conspicuous  example 
of  the  use  of  vital  statistics  on  an  enormous  and  highly 
practical  scale  is  to  be  seen  in  the  life  insurance  companies; 
whose  actuaries  have  been  successfully  occupied  for  years 
in  turning  vital  ratios  into  dollars  and  cents,  —  the  se- 
verest test  of  practicality. 

The  need  of  having  the  care  of  vital  records  of  births, 
marriages  and  deaths  in  charge  of  the  health  department 
and  not  in  the  office  of  the  town  clerk  or  other  non-sanitary 
official  has  been  discussed  in  Part  I.  Only  by  that  ar- 
rangement can  the  records  be  properly  controlled  and  the 
tabulations  be  conveniently  made. 

Twofold  Value  of  Vital  Records.  —  The  records  of 
births,  marriages,  and  deaths  have  two  separate  and  dis- 
tinct uses: 

First,  as  permanent  legal  evidence  of  the  events  to  which 
they  certify.  Until  the  enactment  of  registration  laws, 
births,  marriages  and  deaths  were  registered  only  in  family 
records  and  churches,  and  it  is  unfortunate  that  even 
today,  owing  to  the  deficiency  of  local  records,  recourse 
must  sometimes  be  had  to  those  uncertain  sources.  Be- 
cause of  their  important  legal  functions  the  absence  of  a 
proper  record  may  cause  grave  inconvenience  if  not  actual 
loss  to  the  individual. 

Second,  as  the  basis  for  vital  statistics.  Every  certificate 
contains  some  information  which  is  for  the  identification 

^  Whipple,  George  C,  "The  Use  of  Vital  Statistics  in  the  Public 
Health  Service,"  Pub.  Health  Jour,  (organ  of  the  Canadian  Public 
Health  Association),  June,  1913. 


492  A  MANUAL  FOR   HEALTH  OFFICERS 

of  the  individual  hut  of  no  use  for  statistical  purposes, 
some  which  has  both  an  identiticalional  and  statistical 
value,  and  finally,  some  which  is  primarily  statistical. 
Birth  certificates,  moreover,  have  a  special  use  as  the  basis 
of  infant  h\gicne  work,  while  death  certificates  of  tuber- 
culosis and  other  diseases  are  of  direct  value  in  the  control 
of  those  diseases. 

REGISTRATION 

The  various  steps  in  registration  are: 

1.  Recording. 

2.  Tabulation  from  records. 

3.  Study  of  statistics  thus  obtained. 

4.  Presentation  and  interpretation  of  results. 
They  will  be  taken  up  individually. 

I.  Recording.^  —  The  first  of  these  steps  presupposes  a 
good  registration  law.  The  laws  of  the  various  states 
diflfer  greatly,  and  the  obtaining  of  a  good  state  system  of 
registration,  being  incumbent  largely  upon  state  author- 
ities, need  not  be  dwelt  upon  here. 

For  the  reporting  of  births  the  time  limit  allowed  in 
various  states  varies  from  24  hours  to  30  days,  while  in  a 
few  instances  there  is  no  law  at  all  on  the  subject.  The 
persons  required  to  report  are:  physicians,  midwives,  and, 
in  the  absence  of  professional  attendance,  the  parents. 
Experience  shows  that  allowing  a  greater  length  of  time 
does  not  tend  to  increase  the  efficiency  of  reporting;  on 
the  contrary,  compliance  with  a  short  time  limit  may 
reasonably  be  expected  if  certificates  are  accepted,  when 
need  be,  without  the  given  name  of  the  child.  In  this  case, 
however,  it  is  necessary  to  see  that  the  name  is  returned 
later,  as  a  legal  correction  to  the  certificate.  It  has  been 
proposed,  in  order  to  obtain  prompt  information  for  the 
purposes  of  infant  hygiene,  that  there  should  be  provision 
for  (i)  a  preliminary  notification  within  a  short  time,  say 

^  See  distinction  between  recording  and  registration,  p.  614. 


VITAL   STATISTICS  493 

24  hours,  after  (he  hirlli,  Kiting  Llic  name  aii<l  .I'Mrcss, 
this  to  ])c  followed  later  by  (2)  a  full  registration.' 

The  laws  governing  the  recording  of  deaths  and  marriaii^es 
vary.  It  is  required  under  efficient  systems  that  the  death 
certificate  be  filed  and  a  burial  or  removal  ])ermit  be  issuerl 
before  the  body  is  permitted  to  be  buried  or  remfjved. 

Good  Registration  and  How  to  Obtain  It. — There 
are  two  requisites  to  good  registration:  first,  that  it  be 
complete;  second,  that  it  be  accurate.  Thus,  the  registrar 
must  not  only  see  that  all  certificates  are  recorded;  he 
must  also  scrutinize  each  one  for  errors  and  deficiencies 
and  refuse  to  receive  incomplete  or  apparently  inaccurate 
certificates. 

While  the  law  is  as  a  rule  state  law,  the  enforcement  of 
it  devolves  first  of  all  upon  the  local  registrar.  This  means 
constant  vigilance,  a  searching  out  of  deficiencies  and, 
frequently,  an  active  campaign  for  good  registration. 
Where  registration  is  poor  the  situation  is  almost  always 
due  to  lack  of  strictness  on  the  part  of  the  local  registrar. 
Most  of  the  physicians  and  others  who  are  remiss  in  their 
duty  of  reporting  are  unconsciously  so  and  need  only  be 
stimulated  to  proper  performance  by  a  clear  statement 
from  the  registrar  dwelling  on  the  importance  of  good 
registration  and  his  intention  of  obtaining  it.  In  those  few 
instances  where  notification  is  disregarded  the  guilty  party 
should  be  brought  to  book  and  made  to  pay  the  legal 
penalty.  The  physician,  being  protected  in  the  practice  of 
his  profession  by  the  state,  should  be  all  the  more  active 
in  complying  with  the  state  law,  by  reporting  his  births 
promptly. 

Reporting  of  deaths  is,  in  general,  much  better  than 
that  of  births,  owing  to  the  now  widespread  practice 
of  requiring  the  death   certificate   to   be  exchanged  for  a 

1  Atherholt,  G.  W.,  Am.  Jour.  Pub.  Health,  1913,  vol.  Ill,  p.  451. 
Such  a  provision  has  been  adopted  in  Massachusetts  (Chapter  280, 
Acts  of  1912). 


494  A   MANaiAL    VOR    IIIIALTII   OFFICERS 

burial  pennit  before  burial  or  removal,  under  severe 
penalty. 

Marriages  should  be  recorded  with  the  same  degree  of 
care  as  the  other  vital  records.  What  has  been  said  in 
regard  to  the  enforcement  of  the  birth  registration  law  ap- 
plies in  principle  here.  In  those  states  where  a  marriage 
license  requirenicnt  is  in  effect,  the  completeness  of  the 
marriage  returns  may  be  checked  up  on  the  license  stubs. 

Every  efficient  registrar  will  devise  various  checks  by 
which  he  can  ascertain  what  deficiencies  there  may  be  in 
the  returns  and  can  locate  the  persons  responsible  for  them. 
Such  data  furnish  a  means  of  extending  the  value  of  the 
statistics  and  at  the  same  time  of  improving  registration. 

Checks  upon  Birth  Records.  —  The  following  checks 
are  applicable  to  birth  recording: 

(i)  All  deaths  of  infants  under  two  years  of  age  should 
be  checked  back  against  the  birth  records  in  order  to 
ascertain  whether  the  births  w^ere  reported,  omitting  of 
course  those  where  the  death  certificate  gives  an  out-of- 
town  place  of  birth.  This  may  conveniently  be  done 
monthly  when  the  certificates  are  being  made  ready  to 
transmit  to  the  state  authorities.  Cases  in  which  the  name 
is  missing  from  the  birth  records  are  made  the  subject  of 
a  visit  to  the  home  for  further  information.  If  it  is  found 
that  the  birth  occurred  in  town  and  that  the  professional 
attendant  failed  to  report,  the  matter  is  then  to  be  taken 
up  with  the  latter.^ 

'  The  following  extract  from  the  Report  of  the  Board  of  Health  of 
Montclair,  N.  J.,  for  1913,  is  illustrative  of  the  defects  found:  "In 
checking  back  the  deaths  of  children  to  determine  whether  the  corre- 
sponding birth  certificates  had  been  filed  we  also  found  gross  irregu- 
larities, especially  in  the  spelling  of  the  family  name.  In  many  cases  it 
was  impossible  to  locate  the  birth  record  from  the  card  index,  and  it  was 
only  by  looking  up  the  record  in  the  original  book,  using  the  date  of 
birth  as  stated  on  the  death  certificate  as  a  guide,  that  the  correspond- 
ing certificates  could  be  found.  Any  method  of  checking  up  the  per- 
centage of  reported  births  from  the  death  records  is  bound  to  be  in  error 


VITAL   STA'ITSTrCS  495 

(2)  It  may  be  feasible  to  make  canvasses  of  certain  dis- 
tricts, obtaining  names,  addresses,  and  dates  of  all  births 
that  have  occurred  within  the  year,  which  may  then  Ije 
checked  back  upon  the  records.' 

unless  the  original  records,  arranged  in  cIironoKjgical  order,  are  searched. 

The  following  illustrates  some  of  the  discrejjancies  found: 

Death  Record  Birtli  Record 

Colone Calama 

Cerona Tchiron 

Steffano Stivale 

Ferrari V^eria 

Entille Intile 

Spariano Spaciamma 

De  Gaita Di  Kito 

Christophi Christianna 

Aoccella Cicollela 

Garis,  Willie Garis,  Nellie 

Ryan  (out  of  wedlock) Phelan 

Sheppard  (out  of  wedlock) Bradley 

Yanno  (out  of  wedlock) De  Angelo." 

1  The  following  is  the  experience  of  Montclair,  N.  J.  (Rpt.  just 
quoted) : 

"In  a  large  section  of  the  town  that  was  canvassed  for  unreported 
births  we  found  only  one  case  in  which  a  physician  had  failed  to  file  the 
return,  and  he  claimed  that  he  had  mailed  it,  but  we  found  about  a 
dozen  cases  in  which  midwives  had  not  made  returns  and  we  also  found 
that  there  were  gross  errors  in  names,  dates  of  birth,  and  in  other  par- 
ticulars on  many  of  the  certificates  that  had  been  filed  .  .  .  Our  birth 
records,  will  not  be  complete  until  a  yearly  house-to-house  inspection 
of  the  entire  town  is  made  for  this  purpose.  Even  if  all  doctors  and 
midwives  reported  all  of  their  births  there  would  still  remain  the  few 
cases  in  which  there  was  no  attendant  at  birth  or  in  which  some  unreg- 
istered person  ofiiiciated." 

The  following  procedure  is  also  proposed: 

"We  have  decided  that  we  can  nearly  reach  the  100  per  cent  mark  in 
birth  registration,  and  also  gain  the  great  advantage  of  having  accurate 
records,  by  the  following  method:  As  soon  as  a  certificate  of  birth  is 
filed  a  transcript  is  made  on  a  specially  attractive  form  and  sealed  with 
the  official  seal  of  the  office.  This  copy  is  mailed  to  the  parent  of  the 
child,  together  with  a  circular  letter  in  which  the  importance  of  accurate 
birth  registration  is  outlined  and  in  which  the  request  is  made  that  the 


496  A  MANUAL  FOR   HEALTH  OFFICERS 

'  Health  department  nurses  and  inspectors,  if  alert,  may 
in  the  course  of  their  rounds  learn  of  births  and  may  be  re- 
quired to  keep  regular  lists  of  these,  with  data  as  to  name, 
date  and  place  of  birth,  to  be  checked  up  on  the  records. 

(3)  The  records  of  hospitals  may,  through  the  courtesy 
of  the  hospital  authorities,  be  examined  at  least  once  a 
year  for  comparison  with  the  official  birth  records.  There 
may  be  a  lack  of  understanding  between  institution  and 
physicians  through  which  there  is  failure  to  report. 

Checks  upon  Marrl\ge  Records.  —  Marriages  may  be 
checked  up  through  the  marriage  licenses  where  these  are 
required  by  law.  Otherwise  announcements  published  in 
the  newspapers  may  be  used  as  a  partial  check. 

Checks  upon  Death  Records.  —  The  records  of  ceme- 
teries may  be  compared  from  time  to  time  to  ascertain 
whether  any  burials  have  taken  place  without  the  legal 
filing  of  a  death  certificate  (or  whether  burial  permits  have 
been  obtained  In  the  wrong  sanitary  district,  as  sometimes 
occurs).  Access  to  the  records  of  deaths  in  hospitals  may 
also  be  obtained.  The  law  requiring  proper  burial  per- 
mits should  be  very  strictly  enforced  and  the  practice  of 
burying  first  and  obtaining  a  permit  afterward  should  not 

record  be  returned  for  correction  if  errors  are  noted.  [Text  of  letter 
given.]  ...  It  is  expected  that  parents  will  soon  learn  that  they 
should  receive  such  a  certificate  and  will  send  to  the  ofiSce  for  it  in  case 
they  do  not  receive  one  so  that  we  will  thereby  obtain  a  record  of  un- 
reported births.  We  believe  that  errors  will  be  corrected  promptly  and 
the  value  of  the  certificates  thereby  greatly  increased.  We  expect  that 
the  school  authorities  will  cooperate  by  requiring  the  presentation  of 
such  a  certificate  upon  admission  to  school,  so  that  we  will  thereby 
obtain  a  check  upon  the  records  of  children  born  four  or  five  years  ago." 
It  scarcely  needs  be  said  that  all  this  represents  an  effort  for  perfect 
registrative  efficiency  and  one  requiring  considerable  increase  in  clerical 
work.  There  would  also  be  much  extra  work  if  the  certificates  were 
followed  up  in  ignorant  or  foreign  families  whence  they  would  not  other- 
wise be  returned.  The  practicability  of  the  plan  would,  therefore,  de- 
pend upon  the  intelligence  and  cooperation  of  families  and  upon  the 
labor  available  for  its  operation. 


VI'I'AL   S'lATISTICS  497 

be  tolerated.     Burial  without  due  procedure  as  rc(iuired 
by  law  constitutes  a  serious  offence. 

Proper  recording  further  demands  a  proper  system  of 
copying'  and  transcribing  records,  with  regular  returns  of 
the  original  certificates  to  the  state  registration  office.  It 
is  customary  to  make  certified  transcripts  of  the  records 
for  persons  requesting  them  at  a  small  fee,  these  consti- 
tuting prima  facie  legal  proof  of  the  record.  It  is  scarcely 
necessary  to  say  that  the  official  may  not  alter  a  record  in 
any  particular;  this  can  only  be  done  by  the  person  re- 
sponsible for  making  the  return.  If  the  original  certificate 
has  been  transmitted,  a  corrected  certificate  or  other  legal 
form  may  be  made  out  and  filed. 

2.  Tabulation.  —  The  objects  and  methods  of  tabula- 
tion will  be  taken  up  presently. 

3.  Study  of  Statistics  Obtained.  —  This  is  a  most  im- 
portant point,  though  too  frequently  neglected.  Indeed, 
even  to  determine  the  tabulations  required  demands  some 
study  of  conditions  and  of  the  figures  for  previous  years. 
As  Whipple  says,  "the  man  who  merely  tabulates  data 
and  does  not  study  them  is  a  clerk  and  not  a  statistician." 
The  consideration  demanded  is  usually  in  the  nature  of 
analysis,  detection  of  errors  and  fallacies,  and  searching 
into  underlying  factors.  These  matters  will  be  taken  up 
later. 

1  The  best  form  for  permanent  local  copies  of  records  is  probably  a 
series  of  books  into  which  the  certificates  are  copied  by  hand,  an  alpha- 
betical card  index  divided  by  years  being  kept.  Births,  marriages  and 
deaths  should,  of  course,  be  kept  separate.  Stillbirths  should  be  kept 
in  a  separate  book,  also  "late  birth  returns,"  when  deficiencies  in  the 
records  for  previous  j'ears  have  had  to  be  supplied.  Births  may  con- 
veniently be  indexed  under  the  name  of  the  father  (for  births  out  of 
wedlock  under  the  name  of  the  mother)  and  marriages  under  the  name 
of  each  party.  The  chief  disadvantage  of  card  index  systems  is  that 
cards  may  be  misplaced;  this  may  be  guarded  against  by  having  a  lock- 
ing index  such  that  cards  cannot  be  removed,  and  by  checking  up  each 
batch  of  certificates  against  the  index  before  transmittal  to  the  state 
authorities. 


498  A  MANUAL   FOR   IIKALTII  OFFICERS 

.  Finally  come : 

4.  Presentation  and  Interpretation  of  the  statistics,  by 
which  alone  they  can  be  made  clear  and  forceful  to  others 
than  the  official  who  has  made  the  study  and  by  which 
they  become  even  more  cogent  to  him. 

We  have  dealt  thus  far  with  original  statistics,  those 
produced  from  records  in  the  local  health  office.  But  it  is 
sometimes  necessary  for  the  health  officer  to  refer  to  vari- 
ous official  sources.  Here,  while  the  figures  may  be  ac- 
cessible in  convenient  form,  certain  dangers  and  fallacies, 
which  we  shall  mention  in  a  special  section,  must  be  guarded 
against.  We  may  distinguish  three  kinds  of  published 
(official)  statistics  —  federal,  state  and  local.  These  are 
in  ge?ieral  to  be  relied  upon  in  the  order  given,  the  federal 
being  the  most,  and  the  local  the  least  trustworthy. 

For  population  figures  recourse  is  to  be  had  to  the  re- 
sults of  the  Federal  Census,  taken  every  ten  years  —  e.g., 
1900,  1910,  etc.,  —  and,  in  certain  states,  to  the  State 
Census,^  taken  every  ten  years  on  the  half-decade  —  1895, 
1905,  etc.  By  the  use  of  these  figures,  together  with 
proper  estimates  for  the  non-censal  years  (see  p.  504),  an 
accurate  population  basis  for  vital  statistics  may  be  ob- 
tained. 

The  Federal  vital  statistics  of  births  and  deaths,  while 
the  most  trustworthy  that  we  have,  are  subject  to  certain 
limitations  which  the  Census  Bureau  recognizes  and  de- 
scribes. The  United  States  has  as  yet  no  general  statistical 
system  such  as  has  been  established  in  some  of  the  older 
countries.  The  Bureau  of  the  Census  has  been  steadily 
striving  to  improve  the  registration  of  deaths  and  with 
success,  as  is  evinced  by  the  addition  from  year  to  year  of 
states  to  its  "registration  area."  This  registration  area,  it 
may  be  stated,  comprises  those  states  (and  certain  cities 

'  Inquiry  should  be  made  as  to  whether  such  censuses  are  approved 
by  the  U.  S.  Census  Bureau. 


VITAL  STATISTICS  499 

in  other  states)  in  which  the  death  returns  arc  considered 
sufficiently  accurate  to  be  included  in  the  Federal  mor- 
tality tables.  In  1910  it  included  21  states,  and  returns 
were  also  accepted  from  the  District  of  Columbia  (City 
of  Washington)  and  43  other  cities  in  non-registration 
states,  or  a  total  population  of  not  quite  three-fifths 
(58.3  per  cent)  of  the  population  of  the  country.  The 
registration  area  for  births  was  established  later  and  in- 
cludes a  much  smaller  reporting  population  (about  one- 
fourth  of  the  population  of  continental  United  States). 
Without  a  full  registration  of  births  no  correct  infant  mor- 
tality rates  can  be  computed  for  large  areas  in  which  that 
registration  is  deficient.^  The  present  incompleteness  of 
federally-collected  statistics  is,  therefore,  due  to  the  lack  of 
proper  state  and  local  registration. 

The  careful  student  of  vital  statistics  will  notice  certain 
discrepancies  between  the  figures  given  by  local,  state  and 
Federal  authorities  for  the  same  city.  These,  due  to 
differences  in  classification,  differences  in  the  exact  period 
covered,  and  even  to  typographical  errors  and  other  causes, 
have  been  discussed  by  the  Chief  Vital  Statistician  of  the 
Census  in  a  paper  to  which  those  who  wish  to  inquire  into 
the  matter  are  referred. ^ 

However,  from  year  to  year  published  reports  are  on  the 
whole  becoming  more  inclusive  and  trustworthy. 

ELEMENTS   OF   THEORY 

In  statistics  we  deal  with  units  —  such  as  single  cases  or 
deaths  —  the  data  from  which  are  combined  to  form  num- 
bers, which  are  then  considered  as  regards  their  distribu- 
tions and  their  ratios  to  other  numbers. 

1  See  "Birth  Registration,"  Monograph  No.  i,  Children's  Bureau, 
Department  of  Commerce  and  Labor,  19 13. 

2  Wilbur,  "The  Necessity  for  Uniformity  of  National,  State  and 
Municipal  Vital  Statistics,"  Am.  Jour.  Pub.  Health,  1913,  vol.  Ill,  no.  5, 
P-  413- 


500  A   MANUAL   FOR   HEALTH   OFFICERS 

First  Principles.  —  In  statistical  work  the  following 
three  rules  must  be  observed : 

(i)  Define  clearly  the  units  which  are  taken  as  a  basis  — 
e.g.,  if  they  are  deaths,  state  exactly  what  deaths  are  in- 
cluded, so  as  to  leave  no  doubt  of  the  scope  of  the  statistics. 
Such  definition  should  be  made  in  the  heading  of  each 
statistical  table.  Mention  also  any  conditions  which  may 
affect  the  value  of  the  figures,  also  any  material  assumptions 
which  are  made. 

(2)  Have  accurate  and  sufficient  data.  The  greater  the 
number  of  separate  units  included,  the  greater  the  ac- 
curacy of  the  figures,  for  incidental  errors  tend  to  counter- 
balance one  another  when  taken  in  large  numbers.  Just 
how  accurate  and  how  numerous  the  data  must  be  is  a 
question  to  be  settled  by  circumstances. 

(3)  Focus  the  figures  on  one  or  a  very  few  points  at  a 
time,  eliminating  so  far  as  possible  all  other  points.  It  is 
frequently  desirable  to  make  a  number  of  separate  tabula- 
tions rather  than  attempt  to  cover  all  the  points  at  issue  in 
one,  which  would  be  too  complex  and  extensive. 

Numbers  may  be  either  absolute  or  relative.  Absolute 
numbers  tell  us  nothing,  for  no  number  is  significant  ex- 
cept by  comparison;  hence  the  statistician  does  not  stop 
with  an  absolute  number,  but  compares  it  or  combines  it 
with  some  other  or  others.  For  example,  to  state  that 
100  deaths  occurred  in  a  certain  town  in  a  certain  year 
means  nothing  unless  the  population  of  the  town  is  known, 
and  for  a  thorough  knowledge  of  the  significance  of  the 
figures  we  should  have  to  know  the  causes  of  the  deaths, 
the  ages  of  the  decedents,  and  other  facts.  From  such  facts 
we  may  form  the  relative  distribution  and  ratios  (or  rates) 
which  alone  are  significant. 

Distributions.  —  If  a  number  be  made  one  of  a  series 
so  that  its  relation  to  the  rest  of  the  series  is  apparent, 
useful  comparisons  may  be  made.  This  is  what  is  done 
when  the  death  rate  of  a  town  for  one  year  is  compared 


VITAf.   STATISTICS  501 

with  the  rates  for  other  years.  Or,  if  a  number  which  con- 
veys little  or  no  information  be  analyzed,  its  components 
may  be  foiuK^  significant.  A  ciuanlity  of  "60  ty[:)hf;ifl  fever 
cases"  would  give  only  a  crude  idea  of  the  tyjihoid  situ- 
ation; but  if  the  distribution  of  the  cases  according  to 
residence,  age,  sex,  source  of  water  and  food  supplies,  etc., 
were  known,  valuable  conclusions  might  Ije  drawn.  Thus, 
if  an  absolute  number  be  made  one  of  a  series  of  relative 
and  comparable  numbers,  or  if  it  be  split  up  into  such  a 
series,  useful  information  may  be  obtained. 

Ratios,  or  Rates.  —  A  distribution  involves  several 
numbers,  whereas  a  ratio  is  the  relationship  of  one  number 
to  another.  Conversion  into  ratios  is  the  commonest  way 
of  making  absolute  numbers  relative  and  comparable. 
This  gives  the  birth  rates,  death  rates,  etc.,  which  play 
so  large  a  part  in  statistics. 

Among  statisticians,  certain  rules  have  been  formulated 
for  the  calculation  of  the  principal  rates  and  other  figures, 
and  certain  terms  have  been  agreed  upon.  Thus  only 
can  rates  be  "corrected"  or  standardized  so  as  to  be  com- 
parable. This  matter  of  standardization  will  be  taken  up 
again  under  the  subject  of  death  rates,  to  which  it  chiefly 
applies. 

Averages,  Maxima,  Minima,  etc.  —  The  health  officer 
need  not  usually  go  into  the  mathematical  theory  of  prob- 
ability, error,  etc.;  his  data  may  usually  be  judged  on 
other  considerations.  One  or  two  cautions  may,  how- 
ever, be  in  place.. 

In  taking  an  average^  (or  arithmetical  mean,  obtained  by 
dividing  the  sum  of  a  number  of  quantities  by  the  number 

^  The  term  "normal,"  which  is  frequently  met  with  in  such  expres- 
sions as  "the  normal  temperature  for  the  month,"  "the  normal  typhoid 
death  rate,"  and  the  like,  is  usually  meant  in  the  sense  of  "average." 
Used  in  this  sense  it  is  likely  to  mislead;  e.g.,  a  death  rate  which  has 
been  for  a  number  of  years  "normal"  to  a  certain  place  may  be  in 
reality  highly  abnormal  when  judged  b^^  proper  public  health  standards. 
The  term  "average"  should  be  used  in  all  such  cases. 


502  A    MANUAL    FOR   HKALTII   OFFICERS 

of  ihe  quantities  taken),  care  must  be  taken  that  the 
number  of  facts  is  sufficiently  numerous  to  insure  a  true 
representation.  Thus,  if  we  average  2  deaths  in  one 
month  with  10  deaths  in  another  the  monthly  average  ob- 
tained is  6,  but  the  significance  of  this  figure  is  much  less 
than  if  the  number  of  months  taken  were  greater,  say  in- 
cluding a  whole  year.  This  can  readily  be  seen  in  such  an 
instance,  where  there  is  so  great  a  variance  from  month  to 
month.  Again,  to  average  the  results  of  only  two  or  three 
analyses  of  a  certain  milk-supply  would  perhaps  be  mis- 
leading, while  the  average  of  a  greater  number  of  samples 
taken  within  a  short  period  of  time  would  give  a  trust- 
worthy figure. 

The  average,  moreover,  is  not  always  the  truly  indicative 
figure.  It  may  frequently  be  the  maximum  or  the  minimum 
which  is  really  required.  A  milk-supply,  for  example, 
might  run  excessively  high  in  bacteria  during  one  or  two 
periods  which  would  be  concealed  in  a  general  average  for 
the  year.  A  water-supply  might  be  subjected  to  occasional 
pollutions  sufficient  to  cause  epidemics  while  its  general 
average  appears  quite  respectable.  In  the  same  way  the 
total  of  the  typhoid  fever  cases  during  a  year  might  give 
no  distinct  indication  of  epidemic  increases  which  had 
taken  place  at  particular  times  during  the  year.  In  other 
words,  averages  give  no  indication  of  distribution  or  vari- 
ation, while  maxima  and  minima  have  the  virtue  of  indi- 
cating undesirable  extremes. 

A  figure  known  as  the  median  is  sometimes  used.  This 
figure  is  such  that  in  a  series  of  quantities  there  are  just 
»as  many  above  as  below  it.  This  figure  is  especially  useful 
and  is  more  indicative  than  the  average  in  any  series 
where  the  distribution  of  the  quantities  is  so  uneven  that 
the  inclusion  of  those  at  one  extreme  unduly  influences  the 
average  obtained.  Thus,  in  the  series  i,  2,  3,  4,  5,  6,  7,  8, 
20,  30,  40,  the  median  is  6,  while  the  average,  on  account 
of  the  three  high  numbers  at  the  end,  is  1 1.5.     In  the  U.  S. 


VITM.   STATISTICS  503 

Registration  Area  in  1910  the  average  age  at  deatli  of 
bronchopneumonia  cases  was  19.7  years;  but  the  median 
was  only  1.5,  showing  the  disease  to  be  one  chiefly  of 
infants,  an  important  fact  not  indicated  by  the  average. 

As  to  theory  and  practical  statistical  work,  it  must  he 
remembered  that  while  in  institutions,  etc.,  and  under 
special  conditions  very  exact  work  is  possible,  in  general 
public  health  work  the  conditions  are  at  present  far  from 
ideal.  The  quantities  dealt  with  are  by  no  means  mathe- 
matically exact,  many  fluctuations  are  unmeasured,  and 
the  health  officer  as  statistician  must  be  constantly  cor- 
recting, elucidating  and  qualifying. 

STATISTICS   OF   POPULATION 

Population  is  the  basis  of  vital  statistics.  The  study  of 
populations  and  of  the  "movement  of  population"  (the 
effect  of  births,  deaths  and  migration)  is  an  important 
branch  of  statistical  science  included  in  the  general  scope 
of  the  science  of  Demography  (a  term  from  the  French 
statisticians,  not  as  yet  in  very  general  use). 

Censuses.  —  A  growing  population  is  subject  to  increase 
by  the  surplus  of  births  over  deaths  (since  births  are  com- 
monly more  numerous  than  deaths)  called  the  "natural 
increment";  it  is  also  influenced  by  migration.  In  the 
United  States,  where  immigration  is  so  much  more  im- 
portant than  emigration,  great  increases  are  experienced 
from  the  latter  cause.  The  total  increase  in  population 
from  time  to  time  is  called  the  "actual  increment,"  being 
the  net  result  of  all  factors  affecting  the  population.  The 
population  is  determined  at  certain  intervals  by  means  of 
a  census,  which  is  taken  as  of  a  certain  definite  date.  The 
United  States  Census,  under  the  Bureau  of  the  Census, 
Department  of  Commerce,  is  taken  every  ten  years  on  the 
even  decades:  1900,  1910,  1920,  etc.  In  addition,  certain 
states  take  a  census  of  their  own  on  the  intermediate  semi- 


504  A  MANUAL   FOR   HEALTH  OFFICERS 

decades:  1905,  191 5,  ctc.^  The  results  of  the  Federal 
Census  are  published  in  a  series  of  bulletins  and  volumes, 
the  19 10  Census  being  known  as  the  Thirteenth. 

Population  Estimates.  —  It  is  necessary  to  determine  the 
population  for  inlcrcensal  years  by  estimation.  For  this 
purpose  various  methods  have  been  proposed.  Since  pop- 
ulations are  subject  to  all  kinds  of  unmeasured  fluctuations, 
any  estimate  is  subject  to  error  and  the  question  arises  as 
to  what  method  is  the  most  dependable. 

This  question  has  been  answered  by  the  Bureau  of  the 
Census,  which,  after  thorough  consideration  of  various 
methods,  recommends  what  is  known  as  the  U.  S.  Census 
method  of  estimation, ^  which  consists  in  arithmetical  inter- 
polation between  and  beyond  the  two  latest  censuses.  In 
other  words  it  assumes  that  the  actual  amount  of  increase 
of  the  population  each  year  is  the  same;  so  that  it  is  only 
necessary  to  take  the  difference  in  population  between  two 
censuses,  divide  by  the  number  of  years  intervening,  and, 
beginning  with  the  earlier  census,  add  that  quotient  for 
each  successive  year.  In  its  simplest  form,  to  illustrate 
the  principle  without  for  the  present  referring  to  the  cor- 
rection for  mid-year  population  which  will  be  taken  up 
below,  the  following  example  is  given. 

Example.  —  The  population  of  a  certain  town  was 
15,321  in  1900,  and  19,542  in  1910.^  The  interval  between 
the  censuses  we  shall  assume  is  exactly  ten  years,  during 
which  the  town  gained  19,542  minus  15,321,  or  4,221  in- 
habitants, an  average  annual  increase  of  (4221  -^  10  =) 
422.1  inhabitants  per  year.  To  obtain  the  populations  for 
the  intercensal  years  simply  add  the  average  annual  in- 
crease, 422  (dropping  the  fraction  for  simplicity),  for  each 
year,  thus: 

1  See  note,  p.  498. 

^  Used  in  the  U.  S.  Census  publications  and  prescribed  for  use  by 
health  officials  and  others  by  the  American  Public  Health  Association 
(Rules  of  Statistical  Practice,  1908). 

^  These  should  be  mid-year  populations,  as  will  be  explained  below. 


VITAL   STATISTICS  505 

Population  for  1900  (census) 15.321 

Add 422 

Population  for  1901  (estimate) 15.743 

422 

Population  for  1902  (estimate) 16,165 

And  so  forth,  the  last  figure  being: 

Population  for  1909  (estimate) 19. 1 19 

Add 422 

[Population  for  1910  (by  addition) 19,5411 
Population  for  1910  (census) I9,542j 

The  last  sum,  being  practically  the  same  as  the  census 
population,  being  a  check  on  all  the  previous  additions. 

To  obtain  the  estimates  for  postcensal  years,  assuming 
that  there  is  no  census  later  than  1910,  simply  continue  on 
as  above: 

Population  for  1910  (census) 19.542 

Annual  addition 422 

Population  for  191 1  (estimate) 19.964 

422 

Population  for  1912  (estimate) 20,386 

Etc.  Etc. 

From  this  example,  for  the  sake  of  simplicity,  is  omitted 
one  noteworthy  feature  of  the  method  —  that  is  the  use  of 
mid-year  populations.  Where  annual  rates  are  to  be  cal- 
culated the  greatest  degree  of  accuracy  will  be  obtained  by 
basing  them  upon  the  assumed  population  at  the  middle 
of  the  year,  July  i.  Formerly  the  Federal  Census  was 
taken  as  of  June  i  of  the  census  year,  and  this  was  so  near 
mid-year  that  the  Census,  in  calculating  rates,  made  no 
correction  for  the  difference.  But  in  1910  the  Census  was 
taken  as  of  April  15,  making  a  difference  of  2|  months  from 
the  middle  of  the  year;  and  beginning  with  1910  the 
Census  has  applied  a  correction  so  as  to  base  its  rates 
upon    mid-year    populations.     Local    registration    officials 


5o6  A   MAXU.\L   FOR   HEALTH  OFFICERS 

should  follow  this  example  and  reduce  all  their  population 
figures  to  a  mid-year  basis.  This  is  the  more  important 
the  more  rapid  the  growth  of  the  community. 

The  process  of  estimating  the  mid-year  populations  for  1900  and  1910 
from  the  census  enumerations  as  of  June  i  and  April  15,  respectively,  is 
very  simple.  In  former  estimates,  when  each  census  was  of  date  June  i , 
the  interval  between  them  was  exactly  ten  years  or  120  months.  The  in- 
terval between  the  census  of  June  i,  1900,  and  the  census  of  April  15, 
1910,  is  not  120  months,  but  only  I18.5  months;  dividing  the  observed 
increase  of  population  for  a  given  area  by  118.5,  the  average  monthly 
increase  during  the  decade  is  obtained.  This  monthly  increase  added 
to  the  population  June  i,  1900,  gives  the  mid-year  population  for  1900, 
and  two  and  one-half  times  the  monthly  increase  added  to  the  popula- 
tion of  April  15,  1910,  gives  the  mid-year  population  for  1910.  One- 
tenth  of  the  difference  between  the  two  mid-year  populations  is  then 
added  successively  for  the  intercensal  years  1900  to  19 10  and  the  post- 
censal  years  beginning  with  191 1  [just  as  in  the  example  above].  Suit- 
able allowance  must,  of  course,  be  made  for  changes  of  area.' 

The  final  check  on  the  postcensal  estimates,  i.e.,  estimates 
made  since  the  latest  census,  lies  in  the  nearness  of  their 
agreement  with  the  results  of  the  next  following  census. 
Thus,  according  to  the  estimation  in  the  above  example, 
the  population  for  1920  would  be  23,762,  but  if  the 
census  of  that  year  should  show  an  actual  population  of, 
say,  22,478,  then  the  estimates  since  1910,  being  in  error, 
must  be  revised  to  agree  with  the  new  figure.  There  is  al- 
ways, of  course,  such  an  error,  greater  or  less,  in  estimated 
postcensal  populations.  Since  the  error  is  frequently  very 
considerable,  good  practice  demands  that  this  rule  be  fol- 
lowed: after  each  census  revise  the  postcensal  estimates  pre- 
viously made:  re-estimate  the  populations,  taking  the  new 
population  figure  into  account,  and  where  necessary  re- 
compute the  rates  based  upon  the  first  and  less  accurate 

1  Annual  Bulletin  on  Mortality  Statistics,  1909,  Bureau  of  the 
Census.  (Quoted  in  Rosenau's  "  Preventive  Medicine  and  Hygiene," 
I9i3>  P-  90I-)  The  U.  S.  Census  method  may  readily  be  applied  by  the 
health  officer  to  the  local  population  figures,  or  the  Census  Bureau  will 
estimate  the  populations  for  any  commuiiil\-  on  request. 


VI'I'AI.   S'I'A'I'ISTICS  507 

population  estimates.  Where  state  censuses  are  taken  in 
the  interval  between  Federal  censuses  they  may,  if  ap- 
proved by  the  Federal  Census  Bureau,  be  made  use  of, 
the  estimation  being  made  throu^di  five-  instead  of  ten-year 
periods. 

DEATHS 

DEATH   RATES 

Of  chief  interest  to  the  health  officer  are  mortality 
statistics,  for  the  information  afforded  by  death  rates  is  of 
the  greatest  importance.  The  following  are  the  general 
definitions  relating  to  death  rates.  The  terms  paired  in 
brackets  are  contrasted  with  each  other. 

A  general  death  rate  is  the  ratio  obtained  by  dividing 
total  deaths  (irrespective  of  cause,  age,  etc.)  into  the 
population  among  which  they  have  occurred.  This  is  the 
common  meaning  of  the  term  "death  rate"  when  used 
without  qualification. 

A  specific  death  rate  is  a  rate  for  a  specified  cause,  for  a 
specified  nationality,  age-group,  or  the  like;  especially 
one  "based  upon  a  specified  or  limited  group  of  popu- 
lation" (U.  S.  Census). 

A  gross,  or  apparent,  death  rate  includes  all  the  deaths 
which  have  occurred  in  a  given  district  in  a  given  time, 
regardless  of  deaths  of  non-residents  occurring  therein. 
An  actual,  or  true,  death  rate  is  one  from  which  the 
deaths  of  non-residents  in  local  hospitals  and  other  in- 
stitutions are  excluded,  while  deaths  of  residents  occur- 
ring in  institutions  elsewhere  are  so  far  as  possible 
included.^ 

1  While  the  terms  used  in  these  two  definitions  are  not  in  general 
or  official  usage,  it  seems  desirable  to  adopt  them  for  present  purposes. 
The  term  "actual,"  while  accepted  in  England,  is  not  yet  familiar  in 
this  country,  nor  is  any  corresponding  term,  because  the  procedure 
as  to  resident  and  non-resident  deaths  mentioned  in  the  definition  is  not 
yet  properly  established  here. 


5oS  A  MANUAL   FOR   HEALTH  OFFICERS 

A  crude,  or  unstandardized,  death  rate  is  one  which  is  un- 
corrected for  the  \arious  factors  of  age  and  sex  distri- 
bution and  the  like,  in  the  population,  which  would  tend, 
aside  from  sanitar\-  conditions,  to  affect  niortahty. 

A  standardized  death  rate  is  one  in  which  mathematical 
correction  is  made  for  such  factors,  usually  for  age  and 
sex  distribution  of  population.' 
A  death  rate  may  be  described  by  more  than  one  of  the 

above  terms.     Thus,  the  general  death  rate  of  a  city  might 

be  the  actual  rate,  but  unstandardized. 

The   standardizing   of   death    rates   requires   a   detailed 

statistical  process  which  need  not  be  described  here.-     It 

It  would  be  very  desirable  to  have  a  provision  of  law  in  every  state 
that  whenever  the  death  of  a  non-resident  occurs  in  a  hospital  (or 
other  institution)  in  any  sanitary  district,  the  local  registrar  should, 
within  a  limited  time,  make  out  a  duplicate  of  the  certificate  and  trans- 
mit the  same  to  the  local  registrar  of  the  district  where  the  decedent 
was  previously  resident.  In  this  way  such  non-resident  deaths  (as  deter- 
mined by  a  stated  rule)  could  be  not  only  subtracted  from  the  statistics 
of  the  district  where  they  occurred  but  do  not  belong,  but  they  could 
also  be  added  to  the  district  where  they  do  rightfully  belong.  Such 
correction  would  be  made  not  only  locally  but  also  by  the  state  regis- 
trar, so  that  all  published  statistics  would  be  "actual."  The  law  could 
readily  be  enforced  by  inspection  of  the  various  local  records  by  state 
registration  officials.  Such  a  provision  would  also  subserve  private 
convenience  in  obtaining  official  data  relating  to  residents  who  have 
died  in  some  other  municipality.  Some  rule  should  also  be  adopted 
relative  to  deaths  of  transients  not  in  institutions.  For  present  status 
of  the  whole  matter  of  deaths  of  non-residents  and  transients  see  Ap- 
pendix E,  Rule  No.  3  of  1908. 

Since  the  numbers  and  rates  published  in  state  and  Federal  reports 
at  the  present  time  are  gross  rates,  local  reports  should,  in  stating  their 
general  figures,  give  both  gross  and  actual. 

Similar  regulations  should  be  made  for  tyirths  in  the  case  of  non-resi- 
dent mothers. 

^  Such  rates  are  frequently  called  "corrected  rates."  The  above  is 
preferred  as  the  term  suggested  by  the  Census  (Mortality  Statistics  for 
1911). 

2  Described  in  Newsholme's  "Vital  Statistics";  and  by  Wilbur,  in 
Rosenau's  "Preventive  Medicine  and  Hygiene,"  1913,  p.  901-  Cf. 
Appendix  IV  of  Whipple's  "Typhoid  Fever,"  1908  (reprinted  from  Ann. 
Rpt.  Mass.  State  Bd.  of  Health  for  1902). 


VITAL  STATISTICS  509 

is  chiefly  of  value  in  comparisons  beLwcen  the  rates  for 
different  communities,  and  hence  is  of  comparatively  little 
interest  to  the  local  health  officer. 

The  rates  published  in  state  and  Federal  reports  at  the 
present  time  are,  except  as  otherwise  specified,  gross  and 
unstandardized. 

Nevertheless,  while  the  standardization  is  infreciuently 
applied,  it  should  constantly  be  borne  in  mind  that  death 
rates  arc  influenced  by  a  large  number  of  factors,  many  of 
which  have  no  relation  to  sanitary  conditions.  It  is  the 
net  effect  of  these  which  is  summed  up  in  the  general  death 
rate,  which  therefore,  while  it  is  an  important  figure,  can- 
not, as  a  sanitary  index,  be  accepted  without  qualification.  In 
fact,  the  general  death  rate  may  give  little  real  indication  of 
the  sanitary  situation,  and  it  becomes  necessary  to  con- 
sider the  specific  rates  for  various  diseases,  ages,  etc.,  in 
order  to  accurately  estimate  health  conditions.  Some  of 
the  various  factors  involved  will  be  taken  up  below. 

The  general  (annual)  death  rate  is  obtained  by  dividing 
the  number  of  deaths  during  the  year  by  the  estimated 
mid-year  population  in  thousands  for  that  year,  so  as  to 
express  the  rate  as  "per  thousand  of  population."     Thus: 

Death  rate  (per  thousand) 

Number  of  deaths  during  year 
Mid-year  population  -^  1000 

Specific  death  rates  are  calculated  in  a  similar  manner, 
though  differently  expressed.  The  common  expression  of 
death  rates  for  specific  causes  is  "per  100,000  of  popula- 
tion" (sometimes  per  10,000),  as  the  expression  of  such 
rates  "per  1000"  would  necessitate  a  clumsy  use  of  deci- 
mals.    Thus,  for  typhoid  fever: 

Typhoid  fever  death  rate  (per  100,000) 

Typhoid  fever  deaths  during  year  X  100 
Mid-year  population  -^  1000 


5IO  A  MANUAL   FOR   HEALTH  OFFICERS 

Such  a  specific  rate  as  that  just  given  is  calculated  upon 
■the  whole  population,  but  there  are  others  which  should  be 
based  upon  a  limited  or  group  population.  Thus,  if  it  is 
desired  to  calculate  the  general  death  rate  of  a  certain  ward 
in  a  city  the  rate  should  be  based,  not  upon  the  whole  pop- 
ulation of  the  city,  but  upon  the  estimated  mid-year 
population  for  that  particular  ward.  The  rule  is,  cor- 
respondence of  figures  is  a  prerequisite  to  combination.  (See 
also  under  Fallacies,  p.  526.) 

The  factors  which  determine  death  rates  may  be  summed 
up  under  three  heads: 

I.  Composition  of  Population.  —  The  nature  of  the 
population  has  an  important  influence  on  death  rates. 
Some  of  the  factors  under  this  head  are  susceptible  of  sani- 
tary control  or  mitigation;  others  are  not.  But  in  any 
case,  all  those  mentioned  in  this  section  constitute  at  least 
initial  disadvantages. 

Thus,  for  example,  in  the  distribution  by  age  a  large  per- 
centage of  the  very  old  or  the  very  young  (the  latter  indi- 
cated by  a  high  birth  rate)  will  tend  to  increase  the  general 
death  rate.  Death  rates  at  various  ages  are  shown  in 
Chart  I,  p.  74.^ 

In  5e:v;  distribution  the  proportion  of  males,  who  experience 
a  higher  mortality  at  most  ages,  tends  to  increase  the  rate. 

Certain  races,  e.g.,  the  negro  race,  tend  to  higher  death 
rates.  In  Richmond,  Va.,  where  37  per  cent  of  the  popu- 
lation is  colored,  the  negro  death  rate  is  80  per  cent  higher 
than  the  white.  The  negro  death  rates  for  the  more 
important  causes  should  be  shown  separately.^ 

*  The  U.  S.  Census  in  its  analysis  of  mortality  has  established  the 
following  sets  of  age-groups:  {A)  Under  I  year,  1-2,  2-3,  3-4,  4-5; 
under  5,  five-year  periods  from  5  to  100,  100  and  over,  unknown  age. 
(B)  Under  i,  1-2,  2-3,  3-4,  4-5,  5-10,  ten-year  periods  from  10  to  100, 
100  and  over,  unknown  age.  See  also  the  grouping  in  Table  i,  p.  73. 
{A)  and  (B)  are  in  accordance  with  the  population  classification  of  the 
Census. 

2  See  Terry,  "The  Negro:  His  Relation  to  Public  Health  in  the 
South,"  Am.  Jour.  Pub.  Health,  1913,  voL  HI,  no.  4,  p.  300. 


VITAL   S'l'ATISTICS  511 

Tfifiorance  and  careless  modes  of  life  among  the  popu- 
lation are  evidently  [jotent  factors  in  increasing  death 
rates. 

2.  Environmental  Factors  not  Subject  to  Sanita- 
tion. —  Among  these  are  to  be  reckoned  climate  and 
weather.  Southern  climates  furnish  the  most  favorable 
conditions  for  the  life  of  disease  germs  in  the  environment, 
for  the  transmission  of  insect-borne  diseases,  make  the 
preservation  of  milk  and  other  foods  difficult,  and  depress 
the  vitality  of  some  individuals.  Such  conditions  may  be 
counteracted  by  sanitation,  but  since  they  cannot  be  re- 
moved by  it,  constitute  a  distinct  handicap.  The  rigorous 
northern  climates  also  have  their  disadvantages,  although, 
on  the  whole,  mortality  is  higher  the  nearer  the  tropics 
are  approached.  Hot  weather  increases  infant  mortality 
through  its  effect  upon  the  infant  organism  and  upon  the 
milk  supplies,  while  cold  weather  favors  pneumonia,  bron- 
chitis, and  other  diseases  of  the  respiratory  system. 
Changeable  weather,  and  particularly  rapid  changes  of 
temperature,  increases  the  mortality  through  its  strain  on 
the  adapting  powers  of  the  feeble,  the  very  old,  and  the 
very  young.  The  various  communicable  diseases  have  an 
incidence  which  varies  with  the  season,  —  intestinal  dis- 
eases in  summer  (cf.  remark  on  typhoid  fever,  p.  193), 
respiratory  and  skin  diseases  (diphtheria,  scarlet  fever) 
in  winter.^  Health  officers  would  do  well  to  include  in 
their  reports  some  comment  on  local  temperature  and 
other  meteorological  conditions,  based  on  official  Weather 
Bureau  data.^  The  relation  between  summer  heat  and 
infant  mortality  is  particularly  important.  Poverty,  with 
the  accompanying  lack  of  sufficient  and  nourishing  food 
and  of  adequate  clothing,  frequently  combined  with  alco- 

^  Cf.  North,  "Seasonal  Diseases  and  Seasonal  Temperatures,"  Am. 
Jour.  Pub.  Health,  1913,  vol.  Ill,  no.  3,  p.  322. 

'  Address  the  nearest  local  weather  office,  or  the  Weather  Bureau, 
Department  of  Agriculture,  Washington. 


512  A  MANUAL  FOR  HEALTH  OFFICERS 

holism,  is  a  potent  adverse  influence  which  need  only  be 
mentioned.  Overwork  and  anxiety  enter  into  the  problem 
as  large  factors.  Lack  of  work  —  "hard  times"  —  pro- 
duces an  injurious  poverty  for  some  of  the  population, 
although  for  others  it  may  necessitate  abstinence  from 
overwork  and  injurious  self-indulgences,^  for  prosperity 
no  doubt  has,  as  well  as  protections  and  advantages,  cer- 
tain incidental  excesses  detrimental  to  health.  On  the 
whole,  an  economic  condition  of  moderate  prosperity 
would  seem  to  be  most  conducive  to  low  death  rates. 

3.  Sanitation.  —  Under  this  head  are  to  be  in- 
cluded all  the  forces  of  public  health  administration 
as  well  as  of  sanitary  works  such  as  water-supply, 
sewerage,  etc. 

One  of  the  adverse  factors  which  might  have  been 
mentioned  in  the  preceding  section  is  congestion  of  the 
population.  This,  while  an  environmental  state  difficult 
of  administrative  modification,  is  the  matrix  of  a  num- 
ber of  sanitary  evils  which  call  for  a  special  degree  of 
control.  Congestion,  the  crowding  of  large  numbers  of 
persons  upon  a  small  area  and  of  families  into  cramped 
dwelling  quarters,  favors  communication  of  disease,  un- 
cleanliness  and  inadequate  ventilation;  while  accompany- 
ing it  are  commonly  poverty,  ignorance,  low  standards 
of  intelligence  and  living,  alcoholism  and  the  like.  These 
influences  show  statistically  in  infant  mortality  and  the 
death  rates  from  tuberculosis  and  other  diseases.  Hence 
it  is  that  urban,  or  concentrated,  populations  present 
greater  sanitary  problems  than  rural,  or  segregated,  popu- 
lations. 

Trades  deleterious  to  health  —  some  subject  to  great,  others 
to  little  modification  by  sanitation  —  may  also  be  men- 
tioned as  a  special  factor  tending  to  increase  mortality  and 
presenting  serious  sanitary  problems. 
1  See  note,  p.  92  f. 


VITAL   S'I'AI'ISTICS  513 

SPECIFIC   MORTALITY    FIGURES 

From  what  has  been  said  it  may  be  seen  that  the  inter- 
pretation of  a  general  death  rate  is  not  an  easy  matter,  and 
especially  that  sanitary  administration  may  not  be  directly 
measured  by  it.  If  the  various  non-sanitary  factors 
change  but  little  from  year  to  year  the  variations  in  the 
general  death  rate  over  several  years  may  be  taken  as  an 
approximate  indication  of  sanitary  conditions.  If  the  non- 
sanitary  factors  are  subject  to  variation,  due  allowance 
must,  of  course,  be  made.  It  is  because  of  the  uncertainty 
of  these  non-sanitary  factors  that  comparisons  of  crude 
general  detith  rates  must  be  made  with  caution.  Es- 
pecially should  comparisons  of  different  communities  (or 
of  sections  of  the  same  community)  be  distrusted  unless  all 
the  factors  are  taken  into  consideration. 

It  is  for  such  reasons  as  these  that  study  of  the  sanitary 
status  of  a  community  demands  analysis  of  the  general 
death  rate  through  the  use  of  specific  mortality  figures.^ 

The  specific  numbers  and  rates  most  frequently  taken 
are  according  to  cause  of  death.  Other  specific  figures  are 
sometimes  used,  as  for  age-groups,  nationalities,  occupa- 

^  A  good  discussion  of  specific  causes  of  death  and  the  scope  and 
significance  of  the  various  terms  is  given  in  U.  S.  Mortality  Statistics 
for  191 1.  In  the  annual  reports  of  the  Superintendent  of  Health  of 
Providence,  R.  I.  (Dr.  C.  V.  Chapin),  for  1905  and  subsequent  years, 
will  also  be  found  illuminating  remarks  on  the  various  specific  causes  of 
death  and  the  statistical  relationships  between  them. 

The  establishment  of  a  sanitary  index  to  include  the  combined  eflFect 
of  the  preventable  causes  of  death  has  been  proposed.  (Batt,  "The 
Establishment  of  a  Sanitary  Index  Based  upon  Certain  Specific  Mor- 
tality Rates,"  Am.  Jour.  Pub.  Health,  1914,  vol.  IV,  no.  2,  p.  132.) 
Such  an  index  would  take  account  of  communicable  diseases  (titles  i  to 
16  of  the  Internat.  list,  excepting  possibly  influenza,  cholera  nostras 
and  dysentery'),  tuberculosis  (all  forms)  and  infant  mortality  (under 
one  year).  It  is  stated  that  the  curve  for  this  index  does  not  always 
follow  the  general  death  rate  from  year  to  year,  hence  the  necessity  for 
consideration  of  specific  rates. 


514  A  MANU.\L   FOR   HEALTH   OFFICERS 

tions,  etc.,  in  combination  with  total  deaths  or  deaths  from 
specific  causes,  but  on  the  whole  tlie  most  light  is  obtained 
through  consideration  of  causes  of  death. 

On  certificates  of  death  as  filled  out  by  physicians,  not 
only  are  thousands  of  different  temis  used  in  the  state- 
ment of  the  cause  of  death,  but  these  terms  are  subject  to 
greater  or  less  inaccuracies  and  are  frequently  combined  in 
such  a  way  as  to  make  determination  of  the  true  cause 
difficult.  It  is  the  problem  of  the  vital  statistician  to 
classify  the  deaths  under  a  limited  number  of  titles,  other- 
wise they  cannot  be  intelligently  studied;  and  those  titles 
must  be  as  exact  as  scientific  nomenclature  can  make  them. 
The  problem  has  fortunately  been  much  simplified  through 
the  system  known  as: 

The  International  Classification  of  Causes  of  Death.  — 
This  classification,  sometimes  called  after  its  originator 
the  "Bertillon  System,"  is  employed  by  the  U.  S.  Bureau 
of  the  Census  and  the  registration  states  and  by  all  pro- 
gressive registration  offices  and  officials.  An  International 
Commission  of  Revision  meets  every  ten  years  for  the  pur- 
pose of  revising  it,  the  latest  revision  having  been  made 
in  1909.  A  Manual  of  the  International  List  is  published 
by  the  U.  S.  Census  Bureau,  as  is  also  a  Physicians'  Pocket 
Reference  which  has  been  distributed  to  all  physicians  in 
the  country  so  that  they  may  aid  in  bringing  about  a 
uniform  and  general  use  of  the  terms.  Both  of  these  pub- 
lications may  be  obtained  on  request,  and  the  former 
should  be  a  ready  reference  book  in  use  by  every  health 
officer  and  registrar. 

In  the  International  List  all  causes  of  death  are  arranged 
under  179  specific  titles,  each  having  a  definite  number  and 
name,  and  only  these  titles  are  used  in  reporting  statistics. 
As  an  example  of  the  simplification  effected:  under  the 
first  title,  "i.  Typhoid  fever,"  are  included  33  separate 
terms  used  in  death  certificates  to  denote  this  disease. 
There  is  also  an  Abridged  Classification  which  consists  of 


VITAL   STATISTICS  515 

only  35  titles,  formed  by  combinations  of  the  extended  list; 
this,  however,  has  a  comparatively  limited  use;  the  titles 
of  the  full  list  should  be  used  in  general  tables  of  causes  of 
death.  It  is  an  invariable  rule  that  in  reports  all  slalements 
and  tabulations  of  causes  of  death  should  be  strictly  according 
to  the  International  Classification. 

The  Manual  issued  by  the  Census  Office  gives  instruc- 
tions for  the  assignment  of  deaths  under  the  Classification 
which  are  indispensable  to  the  registrar  in  making  up  his 
reports.  In  a  third  or  so  of  death  certificates  two  or  more 
"causes"  of  death  are  given,  and  it  is  the  task  of  the 
registrar  to  determine  the  correct  title,  always  bearing  in 
mind  that  it  is  the  real  primary  or  underlying  cause  of  death, 
and  not  mere  complications  or  terminal  conditions,  which 
is  to  be  selected.  Upon  the  care  and  skill  with  which  this 
is  done  will  depend  to  a  great  extent  the  value  of  the  re- 
sultant statistics.  A  knowledge  of  pathology  as  w^ell  as 
familiarity  with  the  International  List  is  required  for  this 
task  and  the  health  officer  if  not  a  medical  man  should 
obtain  medical  advice  in  marking  the  causes  of  death. 
So  far  as  possible  individual  opinion  on  doubtful  cases 
should  be  subordinated  to  the  rules  given  in  connection 
with  the  use  of  the  International  List.  Since  this  matter 
is  fully  discussed  in  the  Manual,  no  further  mention  need 
be  made  here. 

Death  Rate  for  Specific  Causes  of  Death.  —  Rates  for 
specific  causes  of  death  may  be  expressed  in  several  different 
ways  (the  first  of  which  has  already  been  mentioned) : 

(i)  Per  100,000  of  population.  This  is  the  commonest 
and  most  useful  form  of  expression. 

(2)  As  a  percentage  of  the  total  mortality  from  all  causes. 
Of  limited  and  uncertain  value  (see  p.  528). 

(3)  As  related  to  certain  groups  of  the  population.  For 
example,  the  percentage  of  tuberculosis  deaths  among  a 
certain  number  of  workers  in  a  certain  trade.  This  method 
is  very  valuable  in  special  studies  of  occupational  mortality, 


5l6  A  MANUAL  FOR  HEALTH  OFFICERS 

solving  questions  which  cannot  be  touched  through  more 
general  statistics. 

(4)  With  communicable  diseases,  as  a  percentage  of  the 
number  of  cases  of  the  disease.  This  figure  is  sometimes 
known  as  the  "fatality,"  or  "case  mortality,"  or  "percent- 
age mortality." 

Expression  of  Infant  Mortality.  —  The  standard 
form  of  expression  of  infant  mortalit>'  is  the  ratio  of  deaths 
under  one  year  of  age  per  1000  births.^  (Enumerations  or 
estimates  of  population  under  one  year  of  age  are  unreliable 
and  are  not  considered  a  permissible  basis  for  this  ratio.) 
This  figure  is  known  specifically  as  the  "infant  mortality 
rate";  its  employment,  however,  is  sadly  handicapped  by 
deficiencies  in  the  reporting  of  births.  For  this  reason  the 
Census  authorities  state  (191 1)  that  it  is  "impossible  to 
present  satisfactory  rates  of  infant  mortality  for  the  great 
majority  of  states  and  cities." 

The  rate  "deaths  under  five  years  of  age  per  1000  of 
population  under  five  years"  is  also  used.  The  percentage 
of  deaths  under  one  year  (and  under  five  years)  based  on  the 
total  deaths  of  all  ages  may  be  given.  Deaths  of  infants 
under  five  years  of  age  should  be  given  by  age  as  follows: 
by  days  for  the  first  week,  by  weeks  for  the  first  month, 
by  months  for  the  first  year,  and  by  years  for  the  five 
years.     (Sec  Chapter  II,  Child  Hygiene.) 

In  Appendix  G  is  indicated  the  statistical  material  which 
should  be  presented  in  local  board  of  health  reports.  In 
addition  to  such  material  the  health  officer  may  make  any 
special  studies  of  the  local  mortality  that  circumstances 

'  In  order  to  determine  the  infant  mortality  rate  exactly  it  would  be 
necessary  to  consider  what  proportion  of  the  infants  born  in  any  one  year 
die  before  reaching  the  age  of  one  year,  so  that  both  births  and  deaths 
refer  to  the  same  group;  but  as  the  number  of  births  does  not  usually 
vary  too  greatly  from  year  to  year  it  is  more  practical  to  divide  the 
deaths  by  the  births  for  the  same  year,  as  implied  in  the  definition. 


VITAL   STATISTICS  517 

render  desirable,  consisting  in  statistical  investigation,  or, 
perhaps  more  often,  illuminating  comment  upon  iIk-  local 
statistics. 

Errors  in  Death  Certificates.  —  Statistics  being  no 
more  accurate  than  the  original  data  from  which  they  are 
drawn,  registrars  should  be  vigilant  in  obtaining  complete 
and,  so  far  as  may  be  ascertained  by  inspection,  accurate 
certificates.  The  United  States  Standard  Certificate  of 
Death  is  now  widely  used  throughout  the  country.'  It 
contains  twenty  numbered  items,  eleven  of  which  are  of 
statistical  interest,  the  remainder  being  only  of  legal  or 
personal  value.  Special  attention  should  be  paid  to  items 
7  (age),  8  (occupation)  and  17  (cause  of  death).  In  the 
last  instance  the  spaces  for  primary  and  secondary  (con- 
tributory) causes  of  death  should  be  as  exactly  filled  out 
as  the  physician's  knowledge  of  the  case  allows;  and  where 
there  is  uncertainty  in  the  assignment  of  the  certificate 
under  the  International  List  of  Causes  it  may  be  desirable 
to  obtain  fuller  information  from  the  physician.  (Cf. 
the  note  on  the  reverse  of  the  certificate.)  Under  item 
18  (length  of  residence),  care  should  be  taken  that  this 
space  is  filled  in  case  the  death  occurs  in  a  hospital  or 
other  institution;  and  in  such  instances  the  "former  or 
usual  residence"  is  to  be  given  by  place  if  out-of-town  and 
by  street  and  number  if  local.  Only  thus  can  deaths  of 
non-residents  in  institutions  be  separated  and  deaths  of 
residents  in  such  institutions  be  assigned  to  their  proper 
wards,  both  of  which  procedures  are  necessary  for  obtain- 
ing "actual"  death  rates  as  has  already  been  described. 

Relation  Between  Birth  and  Death  Rates.  —  On 
the  whole,  a  high  birth  rate  tends  to  produce  a  high  death 

^  A  discussion  of  its  points  is  given  by  Dr.  Wilbur,  formerly  of  the 
Census  Bureau,  in  Rosenau's  "  Preventive  Medicine  and  Hygiene,"  1913, 
p.  883.  Copies  of  the  certificate  may  be  obtained  on  application  to  the 
Bureau  of  the  Census,  Washington. 


5l8  A  MANUAL  FOR   HEALTH  OFFICERS 

rate.  This  is  due  to  the  inllucnce,  tlirough  the  larger  num- 
ber of  infant  deaths  in  proportion  to  the  population,  of 
the  higher  infant  mortality  occurring  in  the  congested 
districts  where  the  birth  rate  is  high.  This  would  not, 
however,  be  the  effect  if  infant  mortality  were  so  limited 
by  hygienic  measures  that  the  proportion  of  vigorous  per- 
sons of  child-productive  age  counterbalanced  or  outweighed 
the  number  of  infants  dying.  A  high  birth  rate  may, 
therefore,  sometimes  be  taken  as  an  explanation,  though 
never  as  a  justification  of  a  high  death  rate. 

In  some  communities  the  phenomena  of  a  lowered  birth 
rate  (due  to  later  marriages,  voluntary  limitation  of 
families,  etc.)  and  a  lowered  death  rate  (due  to  improved 
hygiene)  go  hand  in  hand. 

How  Far  may  Death  Rates  be  Lowered?  —  It  is  an 
interesting  question  to  just  what  point  the  general  death 
rate  can  be  lowered  in  any  community.  It  is  clear  that 
even  if  all  causes  of  death  except  old  age  were  eliminated, 
there  would  still  be  a  limit  to  the  reduction. 

As  a  general  proposition,  the  level  toward  which  the 
death  rate  would  sink  as  sanitary  measures  became  more 
and  more  effective  would  be  determined  by  the  amount  of 
mortality  from  non-preventahle  causes,  i.e.,  roughly  con- 
stitutional disease,  accidents,  and  old  age.  In  any  given 
community  the  actual  amount  of  such  mortality  would  de- 
pend upon  the  composition  of  the  population  according  to 
age,  sex,  race,  and  upon  environmental  factors  not  subject 
to  sanitary  control  (see  p.  510  f.).  These  vary  greatly 
from  one  community  to  another.  In  one  community  the 
sum  total  of  such  factors  might  produce  an  irreducible 
minimum  death  rate  of  8  per  thousand ;  in  another,  having 
greater  natural  problems,  it  would  be  higher.  The  factors 
often  vary  in  the  same  community  from  year  to  year. 

We  must  repeat  that  the  absolute  level  of  the  general 
death  rate  considered  by  itself,  being  the  resultant  of  many 
factors  both  sanitary  and  non-sanitary,  cannot  be  taken 


VITAI.   STATISTICS  519 

without  analysis  as  an  accurate  gage  of  sanitary  adminis- 
tration alone.  Of  course,  certain  rough  ideas  may  be 
formed.  If  the  rate  is  very  low,  say  Ijelow  12  per  thou- 
sand, there  is  a  presumption  that  there  are  peculiarly 
favorable  conditions  (e.g.,  as  to  ages)  in  the  population.  If 
the  rate  is  very  high,  say  above  20,  there  is  the  presumption 
that  the  mortality  from  infant  mortality,  tuberculosis  or 
other  causes  is  excessive.  But  such  general  presumptions 
are  of  little  value;  detailed  knowledge  of  specific  death 
rates  and  all-important  external  factors  is  demanded. 
Such  knowledge  will  throw  light  upon  the  amount  of  pre- 
ventable mortality.  Then,  the  reduction  of  this  to  zero, 
rather  than  any  calculated  effect  upon  the  general  death 
rate,  is  the  true  goal. 

MARRIAGES 

There  is  little  in  marriage  statistics  to  interest  the  health 
officer.  The  principal  figure  is  the  annual  marriage  rate 
which  is  calculated  in  the  same  way  as  the  death  rate,  as 
"marriages  per  thousand  of  population."  Some  authorities 
prefer  to  give  the  rate  as  "persons  married  per  thousand  of 
population,"  but  this  form  has  not  come  into  very  general 
use.  In  many  states  a  license  (the  local  registrar  usually 
being  the  licensing  official)  is  required  for  marriages  in 
order  that  marriages  contrary  to  the  provisions  of  the 
law  shall  not  take  place.  This  requirement  incidentally 
improves  the  registration  of  marriages  by  making  it  an 
easy  matter  to  check  them  up. 

On  account  of  their  legal  importance  care  should  be 
taken  to  secure  full  and  accurate  registration  of  marriages. 

BIRTHS 

Value  of  Birth  Records.  —  In  spite  of  the  great  legal  and 
statistical  importance  of  birth  records,  the  standard  of 
registration  in  the  United  States  is  much  below  what  it 
should  be.     Deficiencies  in  reporting  by  physicians  are  due 


520  A   MANUAL   FOR   HKALTH  OFFICERS 

not  merely  to  lack  of  realization  of  the  value  of  the  records 
but  also,  more  espociaih-,  to  the  failure  of  rejjistrars  to 
point  out  that  value  and  insist  upon  prompt  and  complete 
registration. 

There  is  hardly  a  relation  in  life  from  the  cradle  to  ihe  grave  in  which 
such  a  record  may  not  prove  to  be  of  the  greatest  value.  For  example, 
in  the  matter  of  descent;  in  the  relations  of  guardians  and  wards;  in 
the  disabilities  of  minors;  in  the  administration  of  estates;  the  settle- 
ment of  insurance  and  pensions;  the  requirements  of  foreign  countries 
in  matters  of  residence,  marriage,  and  legacies;  in  marriage  in  our  own 
country;  in  voting  and  in  jury  and  militia  service;  in  the  right  to  ad- 
mission and  practice  in  the  professions  and  many  pulilic  offices;  in  the 
enforcement  of  laws  relating  to  education  and  to  child  labor,  as  well  as 
to  various  matters  in  the  Criminal  Code  —  the  irresponsibility  of  chil- 
dren under  ten  for  crime  or  misdemeanor,  and  determination  of  the 
"age  of  consent,"  etc.  As  the  country  becomes  more  densely  settled 
and  the  struggle  for  existence  sharper,  many  of  these  matters,  which 
have  hitherto  been  of  minor  significance,  will  take  on  a  deeper  meaning 
and  acquire  greater  importance.^ 

The  chief  statistical  use  of  birth  records  lies  in  their 
being  the  indispensable  basis  for  studies  of  child  life  and 
particularly  of  infant  mortality.  The  calculation  of  the 
"infant  mortality  rate"  depends  directly  upon  a  complete 
registration  of  births,  and  if  that  registration  is  materially 
impaired  the  rate  based  upon  it  is  of  little  or  no  significance. 
"What  do  we  know  about  infant  mortalit}-,  which  we  are 
all  so  anxious  to  prevent,"  asks  Dr.  Wilbur  of  the  Census 
Bureau,  "when  not  a  single  State  or  city  in  the  United 
States  has  the  data  for  a  correct  statement?  It  depends 
upon  the  accurate  registration  of  all  births."  It  is  to  be 
hoped  that  through  the  efforts  of  health  ofificers  and  regis- 
trars this  reproach  will  soon  be  removed  as  it  can  be  if 
registration  laws  are  simply  strictly  enforced. 

'  Dr.  F.  W.  Reilly,  quoted  in  "Birth  Registration,"  Monograph  No. 
I,  Federal  Children's  Bureau,  U.  S.  Dcpt.  of  Labor,  1913,  which  con- 
tains an  important  practical  discussion  of  the  birth  registration  problem. 
(Cf.  pamphlet,  "Why  Should  Births  and  Deaths  be  Registered?", 
published  by  Am.  Med.  Assn.,  535  Dearborn  Ave.,  Chicago.) 


VITAL   STATISTICS  521 

Registration  Methods.  —  A  si>ccial  elfort  should  be  made 
to  obtain  prompt  returns.  Here,  as  elsewhere,  a  return 
postponed  is  not  infrequently  a  return  neglected.  Legal 
provision  should  be  made  (as  is  the  case  in  some  states) 
that  the  given  name  of  the  child  may  be  registered  by 
means  of  a  report  supplementary  to  the  regular  return,  so 
that  there  is  no  necessity  for  delaying  the  latter  on  account 
of  delay  in  naming  the  child.  In  such  case  the  registrar 
should  systematically  follow  up  the  cause  of  unnamed 
infants  and  obtain  the  supplementary  return,  for  from  the 
legal  standpoint  registration  of  the  full  name  is  most  im- 
portant. The  time  limit  for  birth  reporting  varies  in  the  dif- 
ferent states.  The  "model  law"  of  the  Children's  Bureau 
specifies  ten  days,  which  is  certainly  ample.  Prompt 
reports  are  required  primarily  for  the  sake  of  infant  hygiene 
work  and  prevention  of  blindness.  A  very  efTective  plan 
consists  in  requiring  "notification"  of  the  birth  within  36 
hours,  this  to  consist  simply  of  a  statement  of  name,  ad- 
dress, and  date  and  time  of  birth,  to  be  followed  later  by 
complete  "registration."  The  registrar  could  easily  see 
that  the  latter  was  done  in  all  cases.  Of  36-hour  notifi- 
cation in  England,  it  has  been  said  that  no  other  one 
expedient  has  done  so  much  toward  lessening  infant  mor- 
tality in  that  country.  A  statute  of  Massachusetts 
(Chapter  280,  Acts  of  1912)  requires  notification  within  48 
hours,  with  registration  in  full  within  two  weeks. ^ 

Birth  Rates.  —  The  birth  rate  is  calculated  in  precisely 
the  same  manner  as  the  general  death  rate,  being  expressed 
as  births  per  thousand  of  population.  If  all  the  births 
that  have  occurred  in  the  district  during  the  year  are  in- 
cluded, the  rate  is,  strictly  speaking,  a  "gross"  or  ap- 
parent rate.  In  order  to  obtain  the  actual  rate  it  is  neces- 
sary to  exclude  the  births  of  infants  born  in  local  hospitals 

^  In  Montclair,  N.  J.,  midwives  are  required  to  notify  the  health 
office  by  telephone  or  telegraph  immediately  after  being  called  to  attend 
a  confinement. 


522  A   MANUAL    FOR    HEALTH   OFFICKRS 

to  non-resident  parents,  just  as  non-resident  institutional 
deaths  are  cast  out  of  the  death  rate.'  Unfortunately  the 
data  for  separating  such  "non-resident"  births  do  not  ap- 
pear upon  the  standard  form  of  birth  certificate,  but  the 
necessary  information  may  be  obtained  from  hospital 
records  at  the  close  of  the  year  (when  it  should  be  the 
custom  to  check  over  such  records  to  ascertain  that  all 
hospital  births  have  been  reported).  Local  reports  should 
publisli  both  the  gross  and  the  actual  total  numbers  and  rates, 
though  only  the  actual  resident  births  need  be  included  in 
detailed  tabulations.  For  the  non-residents,  however,  a 
statement  should  be  given  of  the  places  of  residence. 

Birth  Certificates.  —  The  United  States  Standard 
Certificate  of  Birth .^  approved  by  the  Bureau  of  the 
Census,  now  adopted  in  substance  in  many  of  the  States, 
contains,  like  the  Standard  Death  Certificate,  items  both 
of  legal  and  of  statistical  value.  Of  these  23  items,  the 
most  important  to  the  vital  statistician  are:  place  of 
birth,  including  address;  date  of  birth;  color,  or  race,  and 
birthplace  of  father;  and  same  items  for  mother.  Some 
forms  of  certificate  include  a  question  as  to  the  use  of 
prophylactic  solution  for  the  prevention  of  blindness  in  the 
newborn,  mainly  as  a  reminder  to  the  physician  or  midwife 
that  this  treatment  should  be  applied  in  all  cases.  The 
Massachusetts  certificate  bears  a  statement  of  the  law 
requiring  reporting  of  ophthalmia  neonatorum,  and  also 
requires  the  physician  to  state  whether  or  not  he  personally 
attended  the  birth,  it  being  a  practice  in  some  instances  for 
physicians  to  sign  certificates  for  midwives. 

Birth  certificates  should  be  examined,  at  time  of  filling, 
for  accuracy  and  completeness,  though  not  so  much  subject 
to  error  as  death  certificates. 

^  Properly,  all  births  by  non-resident  mothers,  whether  or  not  in  hos- 
pitals, should  be  separated.  The  remarks  regarding  non-resident  deaths 
(p.  507  f.)  apply  in  substance  to  non-resident  births. 

*  Copies  of  this  certificate  may  be  obtained  from  the  Census  Bureau, 
Washington. 


VI'I'AL   STATISTICS  52.3 

STILLBIRTHS 

The  one  important  statistical  consideration  here  is  that 
figures  for  stillbirths  must  invariably  be  kept  separate  and 
distinct  from  those  of  births  and  deaths,  not  beini^  inclu/led  in 
either.  It  is  sometimes  unfortunately  impossible  to  de- 
termine whether  some  published  tables  of  births  and  deaths 
are  inclusive  or  exclusive  of  stillbirths.  Therefore,  general 
tables  of  births  and  deaths  should  always  bear  the  state- 
ment "stillbirths  excluded."  There  is  little  in  the  way  of 
statistical  work  in  connection  with  stillbirths,  and  a  brief 
statement  by  causes  (so  far  as  these  are  stated)  is  all  that 
need  usually  be  given.  More  light  on  the  exact  causes  and 
prevention  of  stillbirths  is  needed. 

For  definition  of  stillbirth  and  rules  regarding  still- 
births see  Rules  of  Statistical  Practice  of  the  American 
Public  Health  Association  (Appendix  E). 

MORBIDITY  STATISTICS 

Under  the  head  of  communicable  diseases  we  have 
mentioned  morbidity  statistics,  i.e.,  statistics  of  disease. 
There  is  this  disadvantage  in  dealing  with  morbidity 
figures:  that  they  are  neither  so  full  nor  so  accurate  as 
those  of  deaths.  Nevertheless,  with  improved  methods  of 
diagnosis  and  more  extended  recognition  and  reporting  of 
the  various  diseases,  this  department  of  statistical  science 
will  doubtless  receive  in  future  more  attention  than  at 
present.  Recent  developments  have  brought  about  a 
demand  for  reports  of  diseases  of  occupation  and  of  epi- 
lepsy, feeble-mindedness,  and  the  like,  and  these  are  now 
required  by  law  in  certain  states.  The  same  may  be 
said  of  the  statistics  of  accidents  and  disabilities,  incurred 
in  industry,  and  of  statistics  relating  to  housing,  health  and 
industry,  and  other  related  social  problems,  to  which  ever 
increasing  attention  is  being  directed. 

Morbidity  statistics,  we  may  note  in  passing,  are  not 


524  A   MANUAL   FOR   HEALTH   OFFICERS 

considered  under  the  head  of  vital  statistics  in  the  usual 
sense. 

SOURCES   OF   STATISTICAL   ERROR 

Perhaps  no  other  science  holds  so  many  pitfalls  for  the 
unwary  nor  offers  so  many  hidden  liabilities  to  producing 
false  results  as  statistics.  Traditional  popular  distrust, 
which  unfortunately  has  some  foundation  in  the  careless 
and  prejudiced  uses  to  which  figures  arc  not  infrequently 
put,  should  be  disanned  by  care  and  frankness  in  the  use 
of  statistical  data  on  the  part  of  the  health  officer. 

The  sources  of  statistical  inaccuracy  may  in  general  be 
put  down  under  three  heads:  (i)  mistakes,  (2)  errors  and 
(3)  fallacies. 

1.  Mistakes.  —  Under  this  head  we  include  mistakes  in 
counting  and  copying,  arithmetical  mistakes,  misprints 
and  the  like,  in  the  clerical  work  of  statistics.  Such  are 
not  to  be  tolerated  in  statistical  work,  though,  to  be  sure, 
they  may  creep  in  where  masses  of  such  work  are  per- 
formed. They  must,  therefore,  always  be  guarded  against. 
The  critical  reader  may  compare  figures  given  in  different 
statements  or  tabulations  in  the  same  report  to  see  if  they 
agree'  in  their  common  quantities.  Those  who  compose 
statistics  should  make  use  of  all  feasible  checks,  such  as 
are  suggested  in  this  chapter,  under  "Methods." 

2.  Errors.  —  By  errors  (as  distinct  from  mistakes  or 
blunders)  we  mean  those  inaccuracies  which  are  inherent 
to  a  greater  or  less  extent  in  even  the  most  careful  sta- 
tistical work.  Practical  statistics  is  not  an  exact  mathe- 
matical science,  for  it  is  occupied  in  dealing  with  variable 
quantities  which  can  rarely  be  exactly  measured.  Its 
natural  errors  must  be  accepted,  care  being  taken  to  see 
that  they  do  not  materially  impair  the  practical  value  of 
the  figures. 

Some  of  the  sources  of  ordinary  statistical  error  are  the 
following: 


VITAL   STATISTTCS  525 

(a)  In  the  original  data  (iikcn  from  certificates,  office 
records,  etc.,  which  arc  subject  to  certain  inaccuracies  anrl 
are  sometimes  incomi)lete.  We  have  already  referred  to 
matters  of  this  nature  in  the  paragraphs  on  birtli  and 
death  certificates  above. 

(b)  Lack  of  "correction"  or  standardization  in  nuniljcrs  and 
rates.  The  objects  and  principles  of  such  correction  have 
already  been  referred  to  (p.  5o8f.),  and  while  it  is  not 
usually  feasible  to  "correct"  rates,  nevertheless,  comment 
should  be  made  to  show  the  nature  of  the  allowances  which 
should  be  made.  When  the  need  of  correction  is  entirely 
overlooked  and  produces  serious  error  it  partakes  of  the 
nature  of  a  fallacy  (see  below.  False  Comparisons). 

(c)  The  use  of  too  few  data.  It  is  a  well-recognized  statisti- 
cal principle  that  the  smaller  the  number  of  unit  cases  taken 
the  greater  is  the  relative  error  involved  in  variations. 

For  an  extreme  example,  the  writer,  in  studying  the 
typhoid  fever  death  rates  of  Massachusetts  towns,  found 
that  a  certain  town  had  a  death  rate  in  a  certain  year  which 
was  twice  as  great  as  it  was  the  year  before,  and  that  both 
rates  appeared  to  be  very  excessive,  one  being  40  and  the 
other  80  per  100,000.  But  on  examining  into  the  matter 
it  was  found  that  the  town  had  only  2500  population  and 
that  there  had  been  a  difference  of  but  one  death  between 
the  two  years,  the  deaths  for  the  two  years  having  been  i 
and  2  respectively.  The  difference  of  i  death  had  made  the 
astounding  change  of  40  (per  100,000)  in  the  rate.  Further 
investigation  showed  that  in  many  other  years  there  had 
been  no  typhoid  fever  deaths  whatever,  the  rate  in  those 
years  being,  therefore,  zero.  In  order  to  determine  whether 
the  typhoid  fever  death  rate  of  that  small  town  was  really 
excessive  or  whether  it  was  increased  fortuitously,  so  to 
speak,  by  the  occurrence  of  two  or  three  cases  of  possibly 
outside  origin,  it  would  be  necessary  to  take  the  average 
rate  over  a  series  of  years,  and  thereby  obtain  a  large 
enough   number  of  deaths  to  be  statistically  indicative. 


526  A  MANUAL   FOR   HEALTH  OFFICERS 

And  a  consideration  of  the  numbers  of  cases,  which  are 
about  ten  times  as  numerous  as  typhoid  deaths,  would,  if 
knowledge  of  all  cases  could  be  obtained,  give  a  far  better 
indication.  Of  course,  really  well-marked  outbreaks  in 
single  years  would  be  another  matter. 

Statistical  theory  proves  that  by  increasing  the  number 
of  observations,  the  accuracy  increases  as  the  square  root 
of  that  number.  In  other  words,  the  average  of  16  cases 
or  observations  would  be  subject  to  but  half  the  error  in- 
cident to  an  average  of  4.  Just  how  numerous  the  data 
should  be  to  warrant  reliance  is  a  matter  for  determination 
in  individual  instances.  In  general,  it  must  be  considered 
how  great  an  effect  variations  ordinarily  to  be  expected 
would  have  upon  the  final  statistical  results. 

The  estimation  of  error  is  an  important  part  of  sta- 
tistical work,  and  in  advance  statistics  various  methods  of 
calculating  numerical  error  are  used.  But  in  local  health 
statistics  a  careful  examination  of  the  figures  and  their 
possible  sources  of  error  should  suffice  to  ensure  freedom 
from  errors  of  such  magnitude  as  would  practically  impair 
the  results. 

3.  Fallacies.  —  By  a  fallacy  is  meant  an  illogical  as- 
sumption or  process  which  results  not  merely  in  estimable 
error  but  in  an  essentially  false  conclusion.  Subtle  fal- 
lacies may  be  unconsciously  established,  but  the  more 
common  are  recognized  by  all  statisticians.  They  may 
consist  in: 

(a)  The  use  of  absolute  numbers  instead  of  relative  num- 
bers and  rates. 

(6)  Failure  to  define  terms,  and  the  false  use  of  terms. 
Statistical  terms  having  a  commonly  accepted  meaning 
should  be  used  only  in  that  sense,  and  others  should  be 
clearly  defined. 

(c)  Use  of  irrational  ratios  and  combinations.  Common- 
sense  and  observance  of  the  rule,  correspondence  of  figures 
—  a  prerequisite  to  combinations  —  usually  serve  to  avoid 


VITAL  STATISTICS  527 

this  pitfall,  the  nature  of  which  is  ilhisLratefl  by  tii('  follow- 
ing extract  from  a  recent  editorial  in  tlic  New  York  Times: 

The  mortality  figures  recently  published  by  the  Census  Bureau  have 
been  interpreted  in  some  quarters  to  prove  that  a  man  is  past  his  prime 
at  forty  years.  A  careful  examination  of  the  figures  themselves  shows 
that  this  conclusion  is  utterly  unwarranted.  The  specific  death  rates, 
corrected  for  age  and  sex,  indicate  that,  in  191 1,  14.5  persons  died  among 
every  thousand  males  between  the  ages  of  35  and  44,  while  the  death 
rate  for  women  of  the  same  age  was  only  10.  Between  the  ages  of  45  and 
54  the  specific  death  rate  was  23.3  for  every  thousand  men  and  16.2  for 
every  thousand  women.  Certain  alarmists  have  added  together  these 
specific  death  rates  in  the  attempt  to  show  that  the  mortality  between 
the  ages  of  35  and  54  is  63  per  thousand  of  population.  Statisticians 
know  very  well  that  specific  rates  cannot  be  added  in  this  way,  and  con- 
clusions based  on  such  crude  and  ignorant  manipulation  of  government 
figures  need  occasion  no  anxiety. 

The  principle  has  an  important  bearing  in  occupational 
and  other  statistics  which  should  have  a  specific  basis.  A 
statement,  for  example,  that  the  tuberculosis  death  rate 
among  the  employees  in  a  certain  industry,  say  hatting,  is 
150  per  100,000  as  compared  with  a  rate  among  teamsters 
of  50  is  valueless  if  based  upon  the  general  population,  for 
we  do  not  know  the  relative  total  numbers  of  hatters  and 
of  teamsters.  The  incidence  in  a  certain  group  should  be 
based  upon  the  total  number  of  employees  in  that  group, 
to  be  expressed  in  the  form  of  rational  rates  as  "annual 
deaths  per  1000  of  hatters,"  and  the  like.  (See  also  re- 
marks on  calculation  of  specific  rates,  p.  515.) 

{d)  Fallacious  Comparisons.  —  Perhaps  the  most  com- 
mon statistical  fallacy  lies  in  the  making  of  comparisons 
which  are  false  because  of  failure  to  analyze  the  quantities 
compared.  An  example  will  illustrate.  Several  years  ago 
a  statement  of  the  death  rate  in  the  United  States  Army 
in  the  Philippines  was  made,  calling  attention  to  the  lowness 
of  this  rate  as  compared  with  that  of  most  American  cities. 
The  fallacy  lay  in  the  failure  to  add  that  since  the  army  of 
occupation  was  composed  of  vigorous  men  in  the  prime  of 


528  A   MANUAL   FOR  HEALTH  OFFICERS 

life,  it  would  not  be  predisposed,  apart  from  sanitary  con- 
ditions, to  nearly  as  high  a  death  rate  as  prevails  in  the 
ordinary  city.  It  may  be  that  the  sanitation  was  better, 
but  the  unqualified  statement  did  not  prove  the  point; 
this  only  a  study  of  "corrected"  rates  could  do. 

Again,  cities  with  a  young  and  vigorous  population  can- 
not be  compared,  without  correction,  with  older  cities 
having  a  less  favorable  age  distribution.  Places,  further- 
more, which  are  health  resorts  attracting  advanced  invalids 
will,  aside  from  sanitary  conditions,  have  a  high  death  rate, 
in  the  interpretation  of  which  allowance  should  be  made  for 
the  deaths  of  persons  who  are  virtually  non-residents. 

The  making  of  comparisons  by  the  use  of  the  "ratio  of 
deaths  [from  a  certain  cause,  or  in  a  certain  age-period]  to 
total  deaths"  is  unsound.  Obviously,  such  ratios  will  vary 
greatly  with  the  actual  number  of  total  deaths  and  with 
the  composition  of  the  population.  Specific  rates  based 
upon  total  or  group  population  afford  the  proper  basis  for 
such  comparisons. 

The  rule  to  be  followed  in  making  statistical  comparisons 
is  that  the  quantities  to  be  compared  must  be  so  based  or 
corrected  as  to  be  substantially  comparable  in  respect  to 
the  point  at  issue.  In  the  ideal  comparison  all  conditions 
on  both  sides  would  be  the  same  except  the  one  upon  which 
the  comparison  is  to  be  made. 

(e)  The  rough  use  of  averages  and  other  general  figures 
without  reference  to  conditions  in  detail;  a  point  which 
has  already  been  dwelt  upon.^ 

(/)  The  common  fallacy  of  post  hoc  reasoning,  not  of 
course  confined  to  statistical  study,  according  to  which 
if  a  certain  phenomenon  which  we  call  A  is  followed  by  a 
certain  phenomenon  which  we  call  B,  B  is  erroneously 
supposed  to  be  necessarily  due  to  A.  Thus  it  was  formerly 
thought  that  disinfection  of  clothing  and  other  fomites 
was  effective  in  checking  yellow  fever  because  epidemics 
'  P.  501  f.     Also  Quetelet's  third  rule,  footnote  to  p.  538. 


VITAL  STATISTICS  $29 

happened  to  die  out  after  such  disinfection  iiad  been  per- 
formed; we  now  know  tliat  fomiles  have  nothing  to  do  with 
its  transmission.  As  Whipple  truly  says:  "This  and  other 
fallacies  are  very  likely  to  creep  in  unawares  in  statistical 
work  under  cover  of  apparent  accuracy  and  thorouj^hncss 
of  investigation  implied  by  the  use  of  long  columns  of 
figures."  And  he  adds  this  remark  applicable  to  statistical 
investigation  in  general: 

Bailey  has  well  said  that  the  phrase,  "Other  things  being  equal,"  has 
covered  up  a  multitude  of  sins.  As  a  rule,  the  other  things  are  not 
equal.  He  also  warns  against  the  hidden  errors  that  may  lie  in  the  use 
of  the  terms,  "It  is  undoubtedly  true  that,"  and  "It  is  probable  in  this 
case  that  .  .  .  ."  Of  great  importance  is  it,  therefore,  to  make  sure 
that  the  data  collected  are  sufficient  in  kind  and  number  for  the  purpose 
for  which  the  statistics  are  intended.  No  better  preparation  for  the 
work  of  the  statistician  can  be  had  than  that  given  in  a  course  of  study 
in  formal  logic.  .  .  .  First  of  all  vital  statistics  must  be  used  with 
truth.i 

STATISTICAL  METHODS 

Assuming  that  a  reliable  registration  has  been  obtained 
and  a  proper  system  of  recording  established,  and  that 
there  has  been  mapped  out  a  scheme  of  tabulations  to  be 
made,  the  question  arises:  What  are  the  best  practical 
methods  for  obtaining  the  results  contemplated?  This  is 
a  question  of  clerical  system  and  technique  which  will 
naturally  be  worked  out  in  each  ofifice  and  for  which  few 
details  can  here  be  laid  down. 

Tabulation  Systems.  —  In  devising  methods  of  tabula- 
tion two  requirements  should  be  kept  in  mind:  first  and 
chiefly,  avoidance  or  correction  of  mistakes;  and  second, 
convenience  and  speed.  Since  it  is  difficult  to  avoid  some 
mistakes  in  the  first  working  of  masses  of  data,  the  detec- 
tion and  rectification  of  mistakes  after  the  tabulation  is 
made  and  before  it  is  approved  is  a  most  practical  and 
necessary  requirement,  and  methods  should  be  chosen  with 
this  object  chiefly  in  view.  In  making  tabulations  from 
^  Op.  cit.,  p.  491  supra. 


53©  A  MANUAL   FOR   HEALTH  OFFICERS 

the  original  \ilal  records  it  is  the  usual  practice  to  make  a 
direct  talh"  from  these  records.  To  illustrate:  suppose  that 
a  tabulation  b>'  causes  is  to  be  made  from  a  number  of 
death  records.  It  is  assumed  thai  tlie  records  have  pre- 
viously been  gone  over  and  each  death  marked  with  the 
International  List  number  to  which  it  is  assigned  (see  p. 
514  f.).  A  large  sheet  is  prepared  witli  spaces  marked  ofT 
for  each  cause  (sub-spaces  for  age,  sex,  etc.,  if  desired). 
The  data  are  then  read  off  and  for  each  cause  a  mark  is 
placed  in  the  appropriate  space.  Every  fiftli  mark  is 
made  diagonally  across  the  other  four,  so  that  it  is  very 
easy  at  the  completion  of  the  tabulation  to  count  up 
the  totals.  The  method  is  simple,  but  has  certain  dis- 
advantages, such  as:  difficulty  in  quickly  locating  the 
spaces  on  a  large  sheet  and  the  liability  to  mistake  in  so 
doing,  inconvenience  and  liability  to  mistake  in  making 
corrections,  the  tendency  of  spaces  to  become  cramped, 
and  possibility  of  losing  the  place  in  case  of  interruption. 

For  such  reasons  the  writer  has  adopted  another  method 
of  making  tabulations  which,  though  indirect,  appears  to 
be  somewhat  more  convenient  and  less  liable  to  mistakes. 
This  consists  in  working  with  dummy  certificates  made 
from  the  original  records.  Suppose,  for  example,  that  the 
above  tabulation  of  deaths  is  to  be  made  by  this  method. 
The  death  certificates  having  been  marked  with  the  Inter- 
national numbers  for  causes,  then,  with  one  person  reading 
and  another  marking  (an  arrangement  which  is  more  rapid 
and  safer  than  individual  work),  a  dummy  memorandum  is 
made  for  each  certificate,  bearing  the  desired  data  in  the 
form  of  abbreviations  such  as  the  following: 

Cause  of  death:   by  International  number. 

Sex:   m  or/. 

Color:   iv  or  c. 

Age:   exact  number  or  by  age  period. 

Residence  (for  institutional  deaths):  r  (resident),  nr  (non-resident). 
(Wards  may  also  be  given  for  all  resident  deaths  if  desired,  with 
any  other  data  required  for  tabulation.) 


VITAL   STATISTICS  53 1 

A  dummy  memorandum  c(;ntaining  the  above  items 
would  look  something  like  this: 

Data  Uummy 

No.  of  Records,  324. 
Cause  of  death,  128. 
Resident. 
Male. 
Age,  25. 
White. 

The  number  appearing  in  the  upper  left-hand  corner  is  tlie 
number  of  the  original  record,  to  which  it  is  thus  easy  to 
refer  back  in  case  of  question  or  need  of  additional  data. 
The  data  are  always  placed  in  the  same  relative  positions 
on  the  card,  there  being  space  in  the  example  given  to  add 
any  other  data  desired.  For  making  the  dummies  it  is 
convenient  to  use  cards  about  3x4  inches  of  about  the  same 
stiffness  and  weight  as  used  in  card  indexes.  Paper  slips 
are  undesirable  as  being  very  difficult  to  handle.  Both 
sides  of  the  card  may  readily  be  used. 

When  the  cards  have  been  made,  tabulation  is  a  rapid 
and  simple  process  of  sorting  and  counting,  with  these  ad- 
vantages: that  any  desired  combinations  can  readily  be 
made,  that  the  studies  may  be  extended  or  modified  in  any 
direction,  that  in  the  process  of  counting  the  accuracy  of 
the  sorting  may  be  verified,  that  if  the  totals  do  not  come 
out  correctly  the  error  can  readily  be  found.  The  flexi- 
bility of  the  method,  combined  with  non-liability  to  serious 
error,  is  its  chief  recommendation.  Care  should  be  had  to 
transcribe  on  the  cards  at  the  start  all  data  which  are  to 
be  used,  for  it  is  inconvenient,  though  possible,  to  re-sort 
and  add  data  afterwards. 

In  working  with  large  tables  the  frequent  use  of  the 
ruler  is  recommended.  One  of  the  sources  of  statistical 
mistake  is  confusion  of  columns.  The  eye  finds  it  particu- 
larly difficult  to  follow  through  a  long  horizontal  row,  but 
if  a  straight-edge  be  laid  on  the  sheet  or  page,  ease  and 
accuracy  are  obtained.     This  applies  particularly  to  the 


532  A  MANUAL   FOR  HEALTH  OFFICERS 

abstraction  of  figures  from  extensive  tables  such  as  those 
of  the  Census,  where  the  figures  are  small  and  the  rows  and 
columns  long.  In  tabular  work  the  ruler  is  as  indispensable 
as  the  pencil. 

Methods  of  Computation. — The  arithmetical  oper- 
ations required  in  statistics  may  be  performed  in  the  usual 
manner,  although,  where  many  operations  of  multiplication 
or  division  are  to  be  performed  the  engineer's  slide  rule 
may  be  found  useful.  The  use  of  this  instrument  can 
readily  be  learned  without  special  matliematical  knowledge, 
and  with  it  ratios  may  very  quickly  be  found  to  a  pre- 
cision of  about  I  in  500  (higher  with  the  larger  sizes). ^ 

Methods  of  Checkmg.  —  No  statistical  results  should  be 
utilized  or  published  which  have  not  been  verified  by 
reasonable  and  appropriate  checks.  The  following  are 
general  methods  which  may  be  used : 

(i)  Automatic  Checks.  —  In  some  instances  an  automatic 
check  on  a  series  of  numbers  may  be  obtained  by  addition  or 
otherwise.  An  example  of  this  may  be  found  in  the  popu- 
lation estimates  given  on  p.  505. 

(2)  Repeating.  —  A  calculation  may  be  checked  by 
simply  repeating  it.  In  order  to  avoid  repeating  mistakes 
in  method  or  arithmetic,  it  is  desirable  that  if  possible  the 
re-calculation  be  performed  by  a  second  person,  or  at  any 
rate  at  another  time  when  the  original  details  are  not  too 
vividly  in  mind. 

(3)  Use  of  Alternative  Methods  and  Sources. — A  useful 
check  on  many  figures  consists  in  approximation  obtained 
through  mental  calculation.  Suppose,  for  example,  the 
percentage  ratio  -^^^  is  to  be  calculated.  A  glance  at  the 
figures  shows  that  the  desired  result  will  be  something  over 
20  per  cent  (since  -5%*^  would  be  exactly  20  percent),  and 
apparently  not  far  from  21   per  cent.     Exact  calculation 

•  Discussion  of  tabulating,  adding  and  multiplying  machines  and 
methods  in  use  in  large  statistical  offices  is  beyond  the  scope  of  this 
manuaL 


VITAI>   STATISTICS 


533 


shows  the  correct  figiin;  to  he  21.F  per  cent.  Such  mental 
calculation  made  before  the  exact  calculation  [)revents 
gross  mistakes,  especially  such  as  would  be  the  result  of 
putting  the  decimal  point  in  the  wrong  place,  and  for  some 
figures  it  may  be  a  sufficient  check. 

Where  calculations  have  been  performed  l>y  the  regular 
arithmetical  processes,  the  slide  rule  (see  above)  is  a  useful 
check. 

In  tables,  both  the  columns  (vertical)  and  the  rows  (hori- 
zontal) should  be  added;  a  check  on  additions  may  then 
be  obtained  by  seeing  that  the  grand  total  obtained  by 
adding  vertically  is  the  same  as  that  obtained  by  adding 
horizontally.     In  the  following  example: 


Col.  I 

Col.  2 

Col.  3 

Total 

Row  I 

8 

7 

2 

17 

Row  2 

5 

4 

6 

15 

Row  3 

2 

3 

I 

6 

Total 

IS 

14 

9 

38  =  Grand   total 

the  figure  38,  being  the  sum  of  both  the  vertical  and  hori- 
zontal totals,  checks  all  additions  in  the  table. 

Care  should  be  taken  that  corresponding  figures  appear- 
ing in  dilTerent  tables  be  checked  against  each  other.  It 
is  confusing  and  discouraging  to  consult  a  report  and 
find,  say,  80  deaths  from  pulmonary  tuberculosis  given  in 
the  general  mortality  table  and  only  70  in  the  section  on 
communicable  disease,  without  a  hint  as  to  any  reason  for 
the  discrepancy. 

Certain  graphic  checks  may  sometimes  be  made  use  of. 
Thus  a  plot  may  disclose  variations  which  do  not  so  dis- 
tinctly appear  in  columns  of  figures. 

Deficiencies  in  Data.  —  All  large  masses  of  data  are 
subject  to  deficiencies;  that  is,  in  some  of  the  individual 
cases  the  facts,  even  with  the  greatest  care  in  registration, 
will  not  be  completely  known.     Thus  in  any  given  tabu- 


534  A  MANUAL   FOR   HEALTH  OFFICERS 

lation  there  may  be  some  facts  which  must  be  classified  as 
"unknown"  or  "not  stated."  If  these  are  very  few  in 
number  they  will  not  substantially  impair  the  value  of  the 
tabulation.  It  is  bad  practice  to  endeavor  to  eliminate  the 
figure  for  unknowns  by  distributing  it,  as  is  sometimes 
done,  among  tlie  other  items.  It  should  always  be  sepa- 
rately stated,  giving  thus  a  measure  of  the  residual  defi- 
ciencies which  remain  after  the  data  have  been  made  as 
nearl)'  complete  as  possible. 

PRESENTATION   OF  RESULTS 

The  effective  presentation  of  statistical  results  in  written 
or  published  reports,  through  the  spoken  word,  in  charts, 
exhibits,  etc.,  is  evidently  of  the  greatest  practical  impor- 
tance. Tw^o  principles  apply  here:  first,  that  the  presenta- 
tion should  be  truthful;  second,  that  it  should  be  impressive. 

In  general  there  are  two  methods  of  presenting  statistical 
results:  the  numeric  and  the  graphic.  The  first  of  these 
deals  with  numerical  statements  and  tables,  the  second 
with  plots,  diagrams,  charts,  maps  and  the  like.  Both 
ways  have  their  uses,  and  it  is  even  frequently  desirable  to 
repeat  results,  so  as  to  make  them  clearer  and  more  im- 
pressive, in  two  or  more  different  ways.  Some  minds  are 
more  readily  appealed  to  through  columns  of  figures,  state- 
ments of  ratios  and  the  like,  and  others  through  the  lines 
of  a  diagram. 

I.  Statements  and  Tables.  —  Tables  should  contain  all 
needed  data  and  no  more.  This  statement  seems  obvious, 
yet  reports  are  published  containing  many  pages  of  de- 
tailed statistics  which  are  of  no  apparent  practical  value, 
the  same  reports  omitting  simple  tabulations  which  are 
indispensable  in  any  report.  At  the  present  time  there 
are  great  divergencies  in  the  content  and  form  of  statistical 
health  reports,  a  situation  which  fortunately  seems  likely 
to  be  remedied  through  the  adoption  of  imiform  tables  for 
the  more  important  purposes.     (Cf.  Chapter  VIII.) 


VI'l'AI.   S'l'ATIS'l'ICS  535 

In  line  with  Llic  principle  for  jM-cscntalion  of  tables  is 
one  for  presentation  of  figures:  figures  should  be  presented 
with  adequate  precision  hut  withoitt  unwarranted  refinements. 
Further,  the  degree  of  precision  should  be  evident  from  the 
way  in  which  the  figure  is  stated.  In  this  way  a  factitious 
appearance  of  great  precision  is  avoided.  To  illustrate: 
in  a  population  of  8000  there  occur  117  deaths  in  a  year. 
Computing  the  death  rate  we  obtain  the  figure  14.625  per 
1000.  How  many  digits  after  the  decimal  point  are  to  be 
used  in  expressing  the  result?  Now  the  smallest  possible 
change,  i.e.,  one  death,  would  make  a  difference  of  one 
part  in  117  in  the  computed  rate.  Hence  as  we  express 
the  rate  to  one  part  in  146,  i.e.,  as  14.6,  we  have  done  all 
that  the  figures  warrant.  Expressing  it  as  14.62  would  in- 
dicate an  accuracy  of  one  part  in  1462  which  is  not  war- 
ranted by  the  figures,  the  last  digit  not  being  "significant," 
and  to  do  so  would  be  to  add  a  useless  digit  and  to  indi- 
cate a  degree  of  precision  which  does  not  exist  in  the  data 
taken.  One  to  146  is  of  course  a  greater  degree  of  precision 
than  I  to  117,  but  we  should  not  drop  the  6  in  14.6  and  call 
the  figure  15,  for  then  the  accuracy  would  be  only  i  to  15. 
The  rule  would  be  to  express  this  result  to  an  accuracy  of 
between  i  to  117  and  i  to  1170  (which  is  fulfilled  when  the 
result  is  stated  as  i  to  146  —  i  to  15  and  i  to  1462  being 
outside  the  limits),  and  in  all  such  cases  the  same  prin- 
ciple applies. 

The  degree  of  precision  is  determined  by  the  least  precise 
quantity  in  the  data.  In  the  above  example  it  has  been 
assumed  that  the  death  figure  is  less  precise  than  the  popu- 
lation figure,  although  in  such  cases  usuall}^  the  population 
is  an  estimated  figure  not  more  precise  than  the  deaths  — 
probably  not  as  much  so.  However,  in  case  of  doubt  we 
are  justified  in  expressing  the  result  to  a  figure  that  will 
certainly  do  justice  to  the  data. 

In  dropping  digits  the  nearer  figure  should  be  taken  for 
the  last  digit  retained  according  to  whether  the  one  follow- 


536  A   MANUAL   FOR   HEALTII   OFFICERS 

iiiii  is  iiKirc  or  less  than  5.  14. ()4  would  become  14.6, 
while  14.66  would  become  14.7,  the  di\iding  line  being 
14.65.  If  the  figure  is  14.65,  it  may  be  so  given,  or  it  may 
be  called  14.6  or  14.7,  or,  if  necessary  for  the  sake  of 
accuracy,  it  may  be  worked  out  to  the  next  place  to 
determine  whether  greater  or  less  than  exactly  14.65,  — 
according  to  whatever  rule  is  adopted. 

2.  Graphic  Presentation.  —  We  refer  here  to  the  use  of 
diagrams,  charts,  maps,  etc.  In  most  plots  quantities,  in- 
stead of  being  represented  by  numbers,  are  represented  by 
distances  laid  off  to  a  certain  scale.  In  this  way  their  mag- 
nitudes and  relations  can  frequently  be  apprehended  much 
more  readily  than  from  the  figures.  The  tables  and  figures 
may  give  all  the  data  that  are  needed  and  must  always 
appear,  but  appropriate  diagrams  make  their  import  more 
striking.  Consequently  extensive  health  reports  frequently 
include  diagrams. 

There  are  a  number  of  forms  of  diagrams,  employing 
lines,  bars,  blocks,  circles,  etc.  (for  some  examples  see  the 
charts  in  the  present  volume).  Diagrams  in  two  dimen- 
sions, showing  how  one  quantity  varies  in  relation  to 
another,  are  known  as  "curves"  (see  Chart  i,  p.  74).  For 
percentages  of  a  total  the  circle  (see  Chart  4,  p.  301)  is 
convenient,  the  requisite  number  of  degrees  being  laid  off 
for  each  quantity. 

Diagrams  intended  for  reproduction  by  printing  should 
be  drawn  on  a  large  scale  —  preferably  twice  or  more 
times  as  large  as  the  final  plate  is  designed  to  be,  in  strong 
or  even  coarse  lines;  in  the  reproduction  process  minor 
blemishes  disappear  and  the  lines  appear  much  finer  in  the 
resulting  "zinc  etching"  or  "line  cut,"  as  the  engraving  is 
called.  Such  cuts  are  not  expensive.  Large  size  charts 
used  for  public  exhibitions  and  the  like  are  readily  reduced 
to  any  desired  size. 

In  the  preparation  of  charts  (unless  a  draughtsman  or 
sign-painter  be  employed)  time  may  be  saved  and  neatness 


VITAL   STATISTICS  537 

gained  by  the  use  of  gummed  letters,  which  may  be  ob- 
tained in  I,  ^,  I  inch  and  larger  sizes  in  black,  whit(-,  or 
red  through  any  stationer  or  directly  from  the  Tablet  and 
Ticket  Company  of  New  York. 

In  laying  off  scales  it  will  be  found  convenient  to  make 
use  of  an  "engineer's  scale,"  which  has  six  different  sizes 
of  scales. 

It  is  frequently  desirable  to  have  charts  drawn  by  an 
architect's  or  engineer's  draughtsman,  under  careful  direc- 
tion, and  the  preparation  of  placards  and  the  like  not  de- 
manding accuracy  in  detail  by  a  professional  sign-painter. 

In  style,  charts  of  all  kinds  should  be  simple,  clear  and 
striking,  without  ornament  or  exaggeration. 

Maps  are  frequently  of  value,  especially  in  the  office,  use 
being  made  of  colors,  pins,  spots  and  the  like.  The  "spot 
map"  for  contagious  diseases,  deaths,  etc.,  is  of  this  nature. 
The  short  tacks  having  heads  of  various  colors,  known  to 
the  stationer  as  "routing  tacks,"  are  useful  for  such  pur- 
poses. 

Titles.  —  No  point  is  more  important  and  none  so  fre- 
quently neglected  in  the  presentation  of  statistical  data  as 
the  use  of  full  and  clear  titles,  both  to  tables  and  to  charts. 
Too  often  important  comparisons  are  made  impossible  by 
the  failure  to  state  just  what  a  table  contains,  or  how  it  is 
composed,  or  what  its  purpose  is.  Tables  of  births  and 
deaths,  for  example,  should  always  bear  in  the  title  a 
statement  that  stillbirths  are  (as  they  should  be)  excluded, 
what  exclusions  are  made  (if  any)  and  the  like.  An  o\-er- 
fuU  title  is  far  better  than  a  too  scanty  one.  A  study  of  the 
titles  used  in  the  mortality  bulletins  of  the  U.  S.  Census 
will  be  illustrative  of  "good  form."  Similar  rules  apply  to 
diagrams,  which  also  should  bear  a  statement  as  to  what 
tables  they  are  based  upon.  The  sources  of  figures  which 
are  not  of  local  composition,  such  as  census  figures,  should 
be  stated.  Where  population  figures  are  given  their  exact 
nature  should  be  described:    whether  census  enumeration 


538  A  MANUAL  FOR   HEALTH   OFFICERS 

or,  estimate,  and  if  the  latter,  the  method  of  estimation. 
Estimates  made  (as  they  should  be)  for  the  middle  of  the 
year  are  to  be  described  as  "estimated  mid-year  popula- 
tion." All  special  terms  used  should  be  clearly  defined  or 
indicated.  In  short,  there  should  be  no  question  as  to 
basis,  terms  or  methods. 

Criticism  and  Interpretation.  —  Statistics  are  only  half 
a  report.  Their  significance  must  be  brought  out  by  dis- 
cussion, by  criticism  and  interpretation. 

The  best  form  of  criticism  is  a  discussion  of  deficiencies 
and  their  remedies.  Nothing  so  clearly  marks  a  good 
statistical  report  as  a  frank  appraisal  of  the  figures  for 
what  they  are.  The  statistician's  own  estimate  of  the  de- 
gree of  trustworthiness  of  the  results  is  in  fact  a  necessary 
preliminary  to  a  thorough  consideration  of  the  evidence  set 
forth. 

As  to  interpretation,  there  must  be  freedom  of  bias  as 
to  the  conclusions  to  be  drawn. ^  Erroneous  conclusions 
and  uses  of  figures  are  sure  to  react  sooner  or  later,  and 
frankness,  be  the  results  favorable  or  otherwise,  is  the  best 
policy  in  the  long  run. 

For  those  who  have  to  study  the  reports  from  various 
places  it  may  be  added  that,  aside  from  arithmetical  mis- 
takes, the  chief  deficiencies  in  local  statistics  are:  failure 
to  define  methods  and  terms,  lack  of  comparability  with 

'  The  first  of  the  four  rules  laid  down  by  the  eminent  statistician, 
Quetelet,  was: 

"  I.  Never  to  have  preconceived  ideas  as  to  what  the  figures  are  to 
prove." 

The  others  are  as  follows: 

"  2.  Never  reject  a  number  which  seems  contrary  to  what  you  might 
expect,  merely  because  it  departs  a  good  deal  from  the  apparent  average. 

"3.  Be  careful  to  weigh  and  record  all  the  possible  causes  of  an 
event,  and  do  not  attribute  to  one  what  is  really  the  result  of  the  com- 
bination of  several. 

"4.    Never  compare  data  which  have  nothing  in  common." 

(As  given  by  Newsholme,  "Vital  Statistics.") 


VITAL   STA'f'IS'f'ICS  539 

figures  from  other  places  (or  sometimes  even  with  figures 
from  the  same  place  at  different  times),  and  failure  to  give 
all  of  the  essential  figures  demanded.  Locally  pufjlished 
death  rates  should  he  confirmed  by  comparison  with  the 
rates  published  by  State  and  Federal  authorities.  Some- 
times, too,  through  comparisons  among  the  tables  in  the 
same  report  internal  discrepancies  may  be  discovered. 

The  compilation  of  vital  statistics  can  be  manipulated  in  many  ways, 
and  by  over-estimates  of  population  or  exclusion  of  deaths  for  various 
reasons  the  death  rates  may  be,  apparently,  reduced  so  that  boastful 
claims  of  the  'healthiest  city'  may  seem  to  be  justified.  Such  claims 
are  usually  open  to  question,  and  frequently  will  be  found  to  depend 
either  upon  grave  deficiencies  in  registration,  the  unjustifiable  omission 
of  certain  deaths,  over-estimates  of  population,  or,  perhaps  most  fre- 
quently of  all,  the  utter  ignoring  or  lack  of  knowledge  of  the  fact  that 
general  or  crude  death  rates  are  unreliable  criteria  of  sanitary  efSciency, 
and  that  the  age,  sex,  or  other  peculiar  constitution  of  the  population 
must  be  taken  into  consideration.' 

State  reports  differ  so  much  that  no  general  comment 
can  be  made.  Statistics  so  published  must  be  judged 
partly  on  such  internal  evidence  as  can  be  gleaned  from  a 
critical  study  of  the  figures,  partly  by  comparison  with 
Federal  figures,  and  partly  on  the  estimation  of  the  Federal 
Census  Bureau,  which  classifies  those  states  from  which 
the  returns  are  considered  sufficiently  trustw^orthy  as 
"registration  states." 

THE  PRACTICAL  APPLICATION  OF    VITAL 
STA  TISTICS 

It  is  unfortunate  that  to  many  persons,  including  many 
health  officers,  vital  statistics  are  looked  upon  as  intangible 
calculation  apart  from  practical  endeavor  —  as  historical 
facts  to  be  placed  on  file  rather  than  the  impetus  to  health 
work    in    the    living    present.     The    following    experience, 

1  Wilbur  in  Rosenau's  "Preventive  Medicine  and  Hygiene,"  1913, 
p.  875- 


540  A   IMANUAL   FOR   IIICALTII   OFl'ICKRS 

which,  it  is  to  be  hoped,  is  an  extreme  instance,  illustrates 
the  intensely  practical  nature  of  vital  statistics  when 
properly  applied. 

In  the  summer  of  1910,  I  was  invited  by  a  board  of  county  commis- 
sioners and  board  of  aldermen  to  visit  their  county  town  and  inspect  a 
small  collection  of  water  on  the  outskirts  of  the  town  that  was  supposed 
to  be  responsible  for  a  large  amount  of  their  sickness.  After  looking 
over  the  pond  in  the  morning  and  making  a  general  sanitary  survey  of 
the  town,  I  walked  over  to  the  local  registrar's  office  to  see  how  many 
people  were  d>-ing  and  what  they  were  dying  from.  At  five  o'clock  I 
consulted  with  the  board  of  aldermen,  several  physicians,  and  health 
officers  and  others.  I  called  their  attention  to  the  fact  that  the  small 
collection  of  water  was  but  one  very  small  item  for  consideration  in  their 
health  situation;  that  malaria  had  caused  very  few  deaths  in  their 
town,  and  it  was  doubtful  if  the  pond  had  much  to  do  with  their  malaria 
as  there  were  so  many  other  breeding  places  for  mosquitoes;  that  with  a 
little  ditching  and  kerosene  oil  (I  went  into  details),  the  pond  could  be 
dismissed  as  a  health  menace;  that  whereas  the  pond  was  of  little  con- 
sequence, other  conditions  of  health  in  their  city  were  of  grave  conse- 
quence; that,  taking  statistics  from  their  own  official,  they  had  a  death 
rate  of  27.5  per  thousand  which  meant  12.5  people  out  of  every  thousand 
of  their  population  died  in  excess  of  the  average  death  rate  that  ob- 
tained throughout  the  United  States;  that  for  four  thousand  population 
this  meant  an  annual  unnecessary  loss  of  fifty  lives  to  their  town;  that 
even  if  they  had  a  death  rate  of  fifteen  some  of  the  fifteen  would  be  from 
preventable  diseases  and,  therefore,  the  fifty  lives  lost  must  necessarily 
be  regarded  as  excessive  preventable  deaths;  that  their  records  showed 
a  death  rate  from  tuberculosis  of  three  hundred  and  seventeen  per  one 
hundred  thousand  instead  of  the  average  of  one  hundred  sixty-seven; 
that  their  records  showed  a  death  rate  from  typhoid  of  seven  and  one- 
half  times  the  average;  that  during  the  last  winter  their  town  had  had 
its  share  of  deaths  from  measles  for  sixty  years;  that  this  last  fact  meant 
one  of  two  things;  either  an  extremely  malignant  epidemic  or  more  prob- 
ably inefficient  quarantine;  that  they  were  most  inconsistent  in  having 
required  a  railroad  that  passed  through  the  town  to  build  an  overhead 
bridge  at  a  cost  of  $18,000  because  during  ten  years  the  railroad  had 
killed,  at  a  crossing,  as  many  as  ten  people;  that  the  interest  on  the 
original  investment  of  the  railroad,  and  the  wear  and  tear  of  the  bridge, 
would  amount  to  at  least  $1,500  per  year,  which  they  were  forcing  the 
railroad  to  spend  to  prevent  one  needless  death;  that  while  they  were 
requiring  the  railroad  to  spend  this  amount  to  prevent  one  death,  they, 
the  aldermen,  were  spending  only  $150  to  prevent  fifty  deaths  .  .  . 


VIIAL   STAriS'I'lCS  541 

Since  that  visit,  and,  I  Ik'Hcvc,  laij;cly  as  a  result  of  liiat  visit ,  tliat  town 
and  counly  iiavc  taken  an  unusual  interest  in  )jui>ii(;  healtli  work  .  .  . 
There  arc  many  people  who  will  become  enthused  over  {generalities, 
but  the  practical,  cool  heads  that  we  usually  find  dictating  municipal 
policies  arc  men  who  want  facts,  and  the  only  way  to  reach  this  necessary 
influence  in  bringing  about  sanitary  reforms  is  through  vital  statistics. 
...  As  some  one  has  said,  they  are  the  chart  and  compass  of  the 
sanitarian  and  he  who  attempts  sanitary  campaigns  and  neglects  vital 
statistics  will  sooner  or  later  find  liimsclf  lost  in  a  sea  of  generalities.^ 

REFERENCES 

Wilbur,  "Vital  Statistics,"  being  Section  IX  in  Rosenau's  "Preven- 
tive Medicine  and  Hygiene,"  1913. 

Newsholme,  "The  Elements  of  Vital  Statistics,"  3rd  edition,  London, 
1912. 

"Mortality  Statistics"  and  other  publications  of  the  Bureau  of  the 
Census,  Washington. 

The  reports  of  the  Registrar-General  of  England,  besides  containing 
English  and  International  data,  are  highly  instructive. 

^  Rankin,  "The  Practical  Value  of  Vital  Statistics  in  the  South," 
Am.  Jour.  Pub.  Health,  1913,  vol.  Ill,  no.  5,  p.  453. 


CHAPTER   X 
PUBLICITY 

No  phase  of  public  health  work  in  recent  years  is  more 
striking  than  the  movement  for  popular  education  in  mat- 
ters of  hygiene.  Not  only,  in  the  Earl  of  Derby's  phrase,  is 
"sanitary  instruction  even  more  important  than  sanitary 
legislation,"  but,  under  the  conditions  of  a  democracy, 
neither  legislation,  funds,  nor  public  cooperation  can  be 
obtained,  nor  will  sanitary  regulations  be  thoroughly  effec- 
tive, without  it.  The  term  "instruction"  might  well  be 
taken  to  include  in  a  broad  sense  the  general  teaching  in 
schools  and  colleges,  the  technical  training  of  public  health 
ofificers  and  experts,  and  publicity  for  the  instruction  of 
the  general  public.  It  is  the  last,  however,  that  will  here 
be  specially  discussed. 

Objects.  —  All  sanitary  education  of  any  kind  has  as  its 
object  one  or  both  of  two  things:  the  improvement  of  per- 
sonal hygiene,  and  the  support  of  the  administration  of 
public  hygiene.  With  both  of  these  the  health  officer  is 
concerned,  but  more  immediately  with  the  latter.  When 
an  adequate  support  of  public  measures  shall  have  been 
secured  health  authorities  can  then  turn  their  attention 
more  particularly  to  the  longer  educative  process  of  im- 
proving the  habits  of  the  people.  Publicity,  with  such  an 
immediate  object,  then,  is 

.  .  .  the  indispensable  preliminary  of  legislation  and  the  necessary 
accompaniment  of  effective  administrative  control.  It  is  here  that 
many  of  our  health  administrations  fail  lamentably.  It  is  doubtful  if 
there  is  any  department  of  our  State  and  municipal  governments  whose 
aims  and  methods  are  less  understood  by  the  puljlic  than  the  depart- 

542 


PUBLICITY  543 

ment  of  health.     It  is  apt  to  be  viewed  widi  suspicion  and  antagonism 
by  physicians,  and  with  apathy  and  neglect  i^y  the  laity. 

Particularly  in  smaller  commuiiilies  failure  to  act  by  the  health 
authorities  is  ex[)Iaiiicd  by  lack  of  pul)lic  suj^port.  The  fault  is  often, 
if  not  usually,  that  of  the  department  itself.  The  jjublic  is  not  taken 
into  its  confidence,  and  we  sec  on  every  hand  the  discouraging  spectacle 
of  the  health  officer  plodding  slowly  behind,  instead  of  leading  and 
stimulating  his  local  public  opinion.  An  organized  system  of  publicity 
should  be  in  operation  in  every  health  office  in  the  country.  Wherever 
intelligently  tried,  whether  in  the  greater  cities  or  in  towns  of  smaller 
population,  the  results  are  always  worth  while.^ 

The  foundations  of  sanitary  education  are  naturally  laid 
in  the  home  and  the  school.  With  these,  however,  the 
health  officer  has  little  to  do.  The  selection  of  textbooks 
on  hygiene  to  be  used  in  the  schools  is  a  matter  for  the 
educational  authorities,  though  it  might  sometimes  be 
wished  that  the  health  officer  were  more  often  consulted  in 
regard  to  them.  Fortunately,  well-balanced  school  hy- 
gienes are  now  readily  to  be  had.  Health  mottoes,  and 
even  "jingles"  embodying  single  precepts,  may  also  be 
taught  effectively  (see  p.  262  f.). 

Passing  on  to  the  general  public,  we  find  that  vast  num- 
bers of  people  (even  among  those  otherwise  well-informed) 
are  ignorant  of  many  of  the  simplest  sanitary  principles. 
Were  such  principles  inculcated  by  the  ready  means  of 
publicity,  not  only  would  the  people  benefit  directly,  but 
the  health  department  would  gain  a  much-needed  co- 
operation in  its  public  measures.  The  rate  of  progress  of 
public  health  work  is  determined  by  public  permission. 

Principles.  —  Much  the  same  practical  psychological 
principles  apply  to  all  publicity  work,  whether  it  be  that 
of  the  commercial  advertiser,  of  the  journalist,  or  of  the 
health  officer  seeking  to  instruct  his  public.  The  three 
main  objects  in  the  present  connection  are:    to  (i)   gain 

^  Farrand,  "The  Development  of  Educational  Efforts  in  Public  and 
Personal  Hygiene  in  America,"  Trans.  XV  Internal.  Congress  Hyg. 
and  Demogr.,  1912,  vol.  iv,  part  ii,  p.  438. 


544  A  MANUAL  FOR  HEALTH  OFFICERS 

effective  attention,  (2)  to  impress  and  (3)  to  produce  a 
desire  to  act  or  avoid.  To  attain  these  objects  it  is  only 
necessary  to  observe  a  few  simple  rules.  These  may  be 
studied  out  in  as  great  detail  as  necessary,  by  those  who 
make  a  specialty  of  publicity  work,  in  the  various  manuals 
on  advertising  and  publicity  methods.^  Health  officers  in 
small  places  may,  however,  obtain  a  great  deal  of  excellent 
publicity  material  from  the  sources  wliic^h  make  a  specialty 
of  supplying  it. 

I.  Gaining  Attention.  —  Effective  attention  may  be 
gained  by  the  use  of  originality  in  captions,  cartoons,  charts 
and  the  like,  and  arrangements  of  material  which  bring  out 
strikingly  one  particular  aspect  —  or  at  most  a  very  few 
aspects  —  of  the  matter  at  a  time.  In  a  word,  gaining 
primary  interest  is  largely  a  matter  of  emphasis  and  origi- 
nality. The  object  is  to  avoid  the  commonplace,  while  at  the 
same  time  not  distorting  the  subject.  It  is,  of  course,  easy 
enough  to  attract  attention  through  the  specious  device  of 
exaggerating  one  item  of  the  subject  to  the  detriment  of 
others;  the  proper  method  is  to  present  all  the  essential 
facts  —  which  are  usually  not  many  —  l)ut  at  the  same 
time  afford  a  convenient  "handle"  which  the  mind  cannot 
help  grasping  at  first  sight.  The  various  aspects  by  which 
a  subject  may  be  approached  usually  afford  several  such 
"handles,"  of  which  the  most  appropriate  may  be  chosen. 
As  regards  originality  we  may  add  a  word  of  caution  on 
the  avoidance  of  undesirable  extremes.  In  the  desire  to 
be  novel  and  striking  one  should  avoid  overemphasizing 
aspects  which  excite  disgust  or  dread;  and  on  the  other 
hand,  humorous  devices  should  not  be  permitted  to  dis- 
tract attention  from  the  serious  meaning  to  be  conveyed. 
Joking  and  alarmism  are  equally  out  of  place,  detrimental 
and  unnecessary  for  exciting  a  normal  and  effective 
interest. 

•  Ci.   Dearholt,    "Educational   Pulilicity  in  Offense  and   Defense," 
Am.  Jour.  Pub.  Health,  191 2,  vol.  II,  no.  12. 


PUBLICITY  545 

2.  Producing  an  Impression. — When  attention  has bcc-n 
attracted  to  the  subject  clearness  and  simpHcity  of  language 
must  be  relied  upon  to  convey  the  necessary  message. 
Technical  language  must  be  translated  into  the  language  of 
the  street.  Words  short  and  common  must  take  the  place 
of  the  longer,  more  uncommon  terms  naturally  used  by  the 
scientist.  Note,  for  example,  the  superior  popular  effec- 
tiveness of  the  phrase  "Do  Not  Spit,"  as  compared  with 
"Expectoration  is  Prohibited."  Very  few  ideas  at  a  time, 
and  those  only  of  the  first  importance,  should  be  placed 
before  the  public.  Bulletins,  circulars,  lectures,  should  be 
brief,  without  too  much  detail,  centered  forcefully  about  a 
nucleus  of  thought  that  everyone  will  be  able  to  remember 
without  great  effort  of  thought.  If  the  thought  can  be 
condensed  in  a  striking  epigram  or  catch-phrase,  its  power 
is  vastly  heightened.^  Again,  the  ideas  must  be  presented 
in  a  concrete  form  and  with  such  use  of  homely  analogies 
and  visible  effects  that  people  will  connect  them  with,  and 
carry  them  out  in,  everyday  life.  The  microscopic  or- 
ganisms of  disease,  for  instance,  may  be  vivid  enough  to  the 
bacteriologist,  but  the  layman's  effort  to  visualize  the 
other's  descriptions  has  resulted  in  the  grotesque  microbe 
of  the  comic  supplement.  The  results  would  be  happier  if 
more  emphasis  were  placed  on  the  effects  of  the  germ  and 
the  human  habits  by  which  it  thrives. 

3.  Providing  a  Motive.  —  To  produce  the  desire  to 
act,  or  in  hygiene  frequently  to  avoid  or  refrain  from  the 
forbidden  action,  it  is  clear  that  appeal  may  be  made  to  the 
instinct  of  self-protection.  But  the  motive  of  altruism,  of 
regard  for  one's  neighbors,  should  also  be  invoked.  Per- 
sonal and  civic  pride,  moreover,  are  considerations.  Above 
all,  the  citizen  should  be  made  to  feel  that  he  can  play  his 
personal  part,  however  small,  in  the  sanitary  campaign.  It 
is  he  who  composes  "the  public." 

^  The  "  healthgrams "  used  by  the  Chicago  Department  of  Health 
deserve  special  mention  in  this  connection. 


546  A  MANUAL   FOR   HEALTH  OFFICERS 

A  word  of  warning  may  be  added  as  to  the  danger  of 
exaggeration  involved  in  aiming  to  make  striking  present- 
ments. This  has  been  a  frequent  fault  of  sanitarians  in  the 
past  when  it  was  not  always  otherwise  easy  to  obtain  strict 
obedience  to  regulations.  Fortunately  accuracy  is  com- 
patible with  force  in  statements,  a  fact  recognized  by  the 
Philadelphia  Milk  Show,  which  adopted  the  motto  "To 
enlighten,  not  to  frighten."  The  health  officer  should  make 
no  statements  which  he  cannot  fully  substantiate  or  act 
upon.  Inaccuracy  reacts  upon  its  source.  The  same 
principle  applies  to  the  opposite  temptation,  perhaps  even 
more  common,  to  gloss  over  real  evils. 

Again,  more  emphasis  should  be  placed  upon  remedies 
than  upon  detailed  descriptions  of  menacing  conditions. 
The  human  mind  is  quicker  to  grasp  a  danger  than  to  com- 
prehend the  means  of  avoiding  it. 

Finally,  publicity  work  should  be  specific  and  should  take 
up  one  subject  at  a  time,  driving  it  home  in  different  ways. 
The  endeavor  to  cover  several  subjects  at  once  results  in 
confusion  and  apathy  of  the  popular  mind.  The  effects 
which  have  been  obtained  in  the  publicity  of  the  tuber- 
culosis campaign  exemplify  what  can  be  accomplished  by  a 
concentrated  attack  on  a  matter  of  paramount  importance. 

MODES   OF   PUBLICITY 

/.    THE  PRESS 

Perhaps  the  most  effective  action  of  the  health  officer  in 
the  field  of  publicity  is  to  maintain,  through  careful  state- 
ments, a  good  press  service.  The  press  is  a  great,  in  fact  an 
indispensable,  ally  of  the  health  authorities.  Local  news- 
papers are  always  ready  to  publish  statements  emanating 
from  the  health  office  which  have  a  definite  news  value. 

Value  and  Use  of  the  Press.  —  The  press  far  outranks 
other  forms  of  publicity  in  that  it  is  the  only  means  of  se- 
curing compliance  with  law  through  wide  public  knowledge 


PUBLICITY  547 

that  the  kiw  is  I>eing  enforced,  and  in  (liaL  it  is  j^ruetically 
the  only  means  of  justification  of  the  administration  in  the 
eyes  of  the  general  public.  A  single  conspicuous  account  of 
a  prosecution  for  violation  of  an  important  health  ordinance 
may  accomplish  more  toward  securing  compliance  than  a 
month's  inspection  work.  Through  the  news  columns  the 
skilful  health  officer  may  talk  to  his  public,  explaining  new 
measures,  refuting  objections  and  denying  false  rumors, 
attacking  current  hygienic  mistakes  and  superstitions,  de- 
fending the  health  budget,  allaying  groundless  alarm,  and 
even,  in  case  of  emergency,  warning  the  public  of  sources 
of  danger  —  as,  for  example,  has  actually  happened  in 
instances  where  it  was  necessary  to  issue  warnings  to  "boil 
the  water." 

The  secret  of  being  able  to  talk  thus  with  the  public  lies 
first,  of  course,  in  having  the  confidence  and  support  of  the 
newspaper  editor.  Once  this  point  is  gained,  the  editorial 
columns  as  well  as  the  news  columns  will  speak  for  the  health 
administration.  Secondly,  the  health  officer  must  have  a 
clear  conception  of  what  constitutes  news.  The  "news 
sense"  may  be  acquired  in  a  sufficient  degree  by  the  health 
officer,  yet  it  is  here  that  he  frequently  makes  mistakes. 
For  example:  it  is  desired  to  bring  out  the  means  of  avoid- 
ing the  common  diseases  of  childhood.  If  the  health  officer 
prepares  a  list  of  "Don'ts"  on  this  topic  it  probably  either 
will  prove  unacceptable  to  the  newspaper  or  will  appear  as 
"filler"  in  an  emasculated  and  inconspicuous  paragraph, 
simply  because  it  is  not  news.  But  suppose  the  same  re- 
marks are  made  the  substance  of  an  address  by  the  health 
officer  or  some  prominent  physician  or  are  printed  as  a 
bulletin  and  distributed  through  the  schools;  then  it  is 
quite  possible  that  they  will  appear  in  toto  and  if  striking  in 
expression  receive  editorial  comment.  On  the  same  prin- 
ciple events  relating  to  the  health  department  which  the 
newspapers  see  fit  to  report  should  frequently  carry  with 
them  some  illuminative  comment  by  the  health  officer  or 


548  A  MANUAL  FOR   HEALTH  OFFICERS 

Other  influential  person.  It  is  the  repeated  impressions  on 
the  pubHc  mind,  prockiced  by  such  hits,  that  spell  popular 
education. 

In  the  consideration  of  news  \'alue,  it  is  important  to 
know  what  the  editor  will  consider  the  best  news,  for  it  is 
this  that  he  will  "feature."  It  is  the  special  feature  of  a 
"story"  which  will  be  headlined,  and  many  persons  will 
scarcely  read  beyond  the  headline.  Sometimes  a  com- 
paratively unimportant,  or  even  a  trivial,  matter  will  be 
thus  rendered  conspicuous.  It  is  a  good  rule  always  to 
give  the  press  a  "feature,"  but  one  which  will  serve  the 
cause  of  good  administration. 

Press  Bulletins.  —  In  order  to  guard  against  error, 
important  statements  from  the  health  office  should  be  given 
out  in  writing.  It  is  a  simple  matter,  if  there  is  more  than 
one  local  paper,  to  make  typewriter  carbon  copies  for  each, 
marking  them  with  a  date  and  hour  (for  example,  "For 
release  at  12  noon,  April  25  ")  for  the  guidance  of  the  editors, 
and  giving  them  out  at  least  three  hours,  and  if  possible  a 
day  or  two,  before  the  earliest  paper  goes  to  press.  The 
more  condensed  a  statement  is,  and  the  earlier  it  is  received 
by  the  newspaper,  the  more  likelihood  there  is  that  it  will 
appear  in  full.  Thus,  whenever  possible,  instead  of  send- 
ing in  matter  at  the  last  minute  the  preferable  procedure  is 
to  mark  it  to  be  held  up  until  the  following  day's  edition. 
Such  written  statements  should  bear  a  brief  title  (not  head- 
lines) to  indicate  the  subject. 

Press  Interviews.  —  The  newspaper  reporter  usually 
"covers"  the  health  office  as  part  of  a  regular  "beat." 
There  is  scarcely  any  individual  with  whom  it  is  more  im- 
portant to  keep  on  cordial  and  even  confidential  terms 
than  the  reporter.  Such  relations  are  fraught  with  bene- 
fit to  both  sides.  It  is  an  excellent  practice  to  meet  the 
representatives  of  the  press  every  morning  for  a  few  minutes 
at  a  stated  hour  for  interview.  Everyday  matters  may  fur- 
nish good  news  items,  while  on  the  other  hand  hints  or 


PUBLICITY  549 

rumors  dropped  by  the  reporter  may  turn  oiii  to  ]>(■  of  im- 
portance to  the  health  officer.  If  it  is  desired  tf;  impress 
upon  the  pubhc  some  extensive  subject,  information  may  be 
given  out  piecemeal  and  thus  spread  out  for  se\'eral  days 
in  a  series  (A  news  items;  in  this  way,  too,  a  desirable  run- 
ning interest  in  health  department  matters  is  kept  up  in  the 
public  mind.  At  any  rate  it  is  always  desirable  to  give  out 
something  of  interest,  however  slight.  It  may  sometimes 
be  necessary  to  share  certain  confidences,  and  at  such  times 
the  discretion  of  a  worthy  reporter  may  be  relied  upon.  In 
giving  out  official  news  as  to  cominunicable  disease  and  the 
like,  reference  to  names  should  be  avoided,  as  is  even  re- 
quired by  law  in  some  states.  Such  cases  may  be  referred 
to  in  general  numbers.  Regarding  official  records  in  general 
the  health  officer  should  inform  himself  as  to  legal  provisions 
and  the  desirability  of  making  public  the  facts  contained 
therein. 

Accuracy.  —  It  is  not  infrequently  charged  that  the 
newspaper  press  is  inaccurate,  for  which  reason  some  per- 
sons go  to  the  illogical  length  of  refusing  it  all  confidence.^ 
In  cases  of  inaccurate  reporting  or  writing  certain  palliating 
factors  should  be  taken  into  account:  such  as  the  unfamili- 
arity  of  the  journalist  with  special  fields  of  knowledge  and 
endeavor,  the  necessity  of  haste,  the  difficulties  encountered 
in  collecting  information  in  fragments  or  from  conflicting 
sources,  etc.,  not  as  excusing  all  inaccuracies,  but  merely 
as  indicating  adverse  conditions  which  should  influence 
the  public  official  to  modify  his  judgment  of  the  news- 
paper man  and  to  endeavor  to  decrease  the  latter's 
difficulties  in  these  respects.  Where  a  press  account  is 
misleading,  either  through  misstatement  of  fact,  through 
wrong  implication,   or   through  misplaced   emphasis   (e.g., 

'  It  is  interesting  to  note,  however,  that  in  some  fifty  newspaper 
clippings  relating  to  board  of  health  work,  collected  by  a  press  clipping 
bureau  from  all  parts  of  the  United  States,  the  writer  has  been  unable 
to  find  any  instances  of  apparent  material  inaccuracy. 


S50  A  MANU.-VL   FOR  HEALTH  OFFICERS 

in  the  captions),  the  fact  may  in  some  instances  be 
attributed  to  the  health  official  from  whom  the  infonnation 
originated.  The  latter,  familiar  with  his  specialty,  may 
easily  fail  to  convey  an  accurate  idea  to  the  interviewer,  who 
is  a  layman  so  far  as  sanitary  science  is  concerned.  A 
health  officer,  for  example,  makes  a  hasty  statement  to  the 
effect  that  the  colon  bacillus  has  been  found  in  the  city 
water  several  times  in  i  c.c,  the  finding  indicating  the 
necessity  for  cleaning  up  a  certain  contamination.  The 
reporter,  having  nothing  further  to  go  upon,  returns  to 
his  paper  with  the  statement  that  the  typhoid  germ  (not  an 
unnatural  inference  for  the  layman)  has  been  found  in  the 
city  water  and  that  the  health  officer  considers  the  situa- 
tion serious.  A  little  time  taken  to  explain  the  nature  of 
B.  coli  and  the  significance  of  quantitative  findings,  with  a 
word  of  caution  to  spare  alarm,  would  have  radically  changed 
the  character  of  the  report.  But  familiarity  with  the  sub- 
ject caused  the  sanitarian  to  neglect  all  this.  While  such 
instances  are  perhaps  uncommon,  they  illustrate  the  neces- 
sity for  making  all  such  statements  clear  and  explicit. 

Unusual  Conditions.  —  The  question  may  arise  as  to 
how  far  publicity  may  be  authorized  and  just  what  matters 
should  be  given  out  when  unusual  conditions  prevail,  e.g., 
in  case  of  an  epidemic.  Unless  some  certain  benefit  is 
other\vise  to  be  gained,  it  is  usually  and  rightly  the  policy 
of  health  departments  to  preserve  silence  until  some  degree 
of  publicity  becomes  necessary.  If  only  a  small  super- 
normal number  of  cases  of  communical)lc  disease  exist  no 
notice  wull  probably  be  taken,  but  if  there  is  a  well-defined 
epidemic,  sooner  or  later  the  press  will  appear  with  rumors 
for  confirmation  or  denial  or  facts  for  explanation;  the 
health  officer  must  then  speak. 

To  make  "no  comment"  under  such  circumstances  is 
to  leave  the  reporter  with  only  the  rumors  or  evidence 
which  he  has  collected  elsewhere  to  go  upon,  with  the  in- 
ference that  they  contain  more  or  less  truth,  and  the  publi- 


PUBLICITY  551 

cation  of  these  may  frequently  result  in  proHufinis'  an 
erroneous  or  even  decideflly  harmful  juihlie  imfjression.  To 
avoid  this  serious  danger,  as  well  as  to  avoid  any  sus[)ic,ifm 
of  a  policy  of  concealment,  it  is  wise  to  make  some  flefinite 
statement,  however  brief  or  non-committal.  This  it  is 
always  possible  to  do  with  good  faith  and  a  regard  for  truth, 
and  if  credible  information  has  come  to  the  notice  of  the 
press  it  has  a  virtual  right  to  such  a  statement.  Moreover, 
it  is  in  many  cases  wise  to  be  absolutely  frank  with  the 
newspaper  men  in  telling  them  all  the  essential  facts  in 
confidence,  at  the  same  time  pointing  out  those  aspects,  the 
publication  of  which  would  be  deleterious  and  indicating 
just  what  statement  may  truthfully  be  made  with  the 
approval  of  the  health  officer.  Such  confidence  will  always 
be  respected  by  the  reputable  newspaper  man  and  will  con- 
tribute greatly  to  easing  the  situation  and  establishing 
mutual  good  relations.  The  safest  plan  is  to  give  out  a 
careful  written  statement  accompanied  by  confidential 
discussion. 

Suppose,  for  example,  that  there  is  an  outbreak  of  typhoid 
fever,  on  which  no  data,  except  the  increased  number  of 
reported  cases,  have  as  yet  been  ascertained.  The  first 
bulletin  may  well  contain  a  statement  of  the  number  of 
cases,  with  the  comment  that  this  should  lead  to  no  appre- 
hension on  the  part  of  the  citizens  at  large ;  it  may  be  added 
that  the  matter  is  under  investigation,  certain  facts  are 
being  ascertained,  etc.  By  the  next  day  the  distribution 
of  cases  may  perhaps  have  been  sufificiently  determined  to 
show  that  only  a  restricted  locality  is  seen  to  be  affected. 
A  statement  may  then  be  given  out  that  one  possible  source 
—  the  general  city  water  supply  —  has  been  exonerated. 
This  furnishes  reassurance  and  a  new^s  story.  As  further 
progress  is  made,  the  facts  may  be  announced  in  a  careful 
manner  until  it  can  be  stated  that  the  source  of  the  epidemic 
has  been  run  down  and  is  under  control.  In  all  of  this  the 
mention  of  personal  names  and  details  should  be  avoided; 


552  A  MANUAL   FOR   HEALTH   OFFICERS 

cases  should  be  mentioned  by  numbers  and  general  location, 
and  special  care  should  be  taken  to  spare  so  far  as  possible 
mention  of  persons  whose  reputations  or  business  might 
be  unjustly  injured.  Such  a  policy  of  frank  but  cautious 
pu])licit>'  will  both  allay  public  anxiety  and  increase  con- 
fidence in,  and  respect  for,  the  health  administration. 

//.    PRINTED   MATTER 

Important  as  is  the  press  as  a  means  of  general  publicity, 
it  has  the  drawback  that  the  health  officer  is  unable  to 
govern  directly  the  impression  to  be  made  on  the  public. 
This  difficulty  is  absent  in  the  "literature"  of  the  health 
department  —  the  various  bulletins,  pamphlets,  circulars, 
leaflets  and  posters  which  it  may  issue  from  time  to  time, 
usually  for  special  purposes.  In  these  the  health  officer 
has  a  free  hand,  subject  to  the  general  publicity  principles 
already  set  forth,  and  through  them  can  reach  directly  the 
more  intelligent  portion  of  the  community. 

Bulletins.  —  It  is  desirable,  circumstances  permitting, 
that  the  larger  municipal,  as  well  as  the  state,  health  de- 
partments publish  regular  monthly  bulletins  containing 
popular  educational  matter  and  setting  forth  concisely  the 
state  of  the  public  health.^  In  such  bulletins  emphasis 
should  be  laid  upon  matters  within  the  comprehension  of 
the  average  citizen  and  in  which  his  cooperation  is  feasible, 
rather  than  upon  tables  of  statistics.  A  mistake  has  been 
made  in  some  instances  of  printing  detailed  tables  of  vital 
statistics  and  other  matters  of  permanent  record  but  not  of 
popular  interest,  in  space  which  might  much  more  profitably 

1  Health  bulletins  are  now  issued  regularly  by  a  number  of  state  and 
municipal  health  departments.  Among  the  former  we  may  mention 
especially  California,  Kansas,  Massachusetts,  New  York,  North  Caro- 
lina and  Virginia;  among  the  latter,  Chicago,  New  York  and  (as  an 
example  of  a  small  city)  Asheville,  N.  C.  See  Greeley,  "  What  the 
States  and  Cities  of  the  United  States  are  doing  in  Public  Health  Ed- 
ucation Work,"  Am.  Jour.  Pub.  Health,  1914,  vol.  IV,  no.  9,  p.  733. 


PUBLICITY  553 

have  been  utilized  in  i^riiilin^  simple  aiifl  interesting  in- 
structive matter.     An  apt  cartocMi  is  always  in  order. 

If  a  periodic  bulletin  is  published,  advance  copies  should 
be  sent  to  the  local  press  several  days  before  issuance  of  the 
regular  edition.  Some  boards  of  health,  e.g.,  those  of 
Montclair,  N.  J.,  and  Palo  Alto,  Cal.,  arrange  with  a  local 
newspaper  to  print  each  week  in  this  paper  a  "board  of 
health  corner,"  the  material  being  furnished  by  the  health 
officer.  In  this  "corner"  or  column,  which  takes  the  place 
of  a  circular  bulletin,  a  very  brief  r6sum6  of  the  week's 
work  of  the  health  department  is  given,  including  numljers 
of  cases  of  communicable  diseases  and  deaths  from  principal 
causes,  some  public  health  subject  is  treated  in  a  popular 
manner  in  a  short  essay,  and  questions  on  puljlic  health 
topics  are  answered  by  the  health  officer.  This  is  a  useful 
means,  not  only  of  disseminating  information,  but  also  of 
putting  to  rest  rumors  as  to  the  communicable  disease 
situation,  etc.  It  must,  however,  be  remarked  that  the 
maintenance  of  any  such  regular  service  places  a  consider- 
able demand  upon  the  time  and  thought  of  the  health  officer 
and  had  better  not  be  attempted  unless  there  is  certainty 
that  it  can  be  constantly  kept  up. 

Reprints  from  Annual  Report.  —  Another  thing  that 
may  be  done,  more  easily  and  with  good  effect,  is  to  reprint 
those  portions  of  the  annual  health  report  which  are  of 
especial  interest  to  the  public:  for  example,  the  sections 
giving  the  ratings  of  milk  dealers,  dealing  with  special 
problems  in  which  the  cooperation  of  the  public  is  desired, 
and  the  like.  This  has  been  done  by  the  health  department 
of  Montclair,  N.  J.,  for  several  years,  copies  being  dis- 
tributed to  every  dwelling  in  the  city,  and  the  cooperation 
gained,  especially  in  eliminating  the  undesirable  milk  dealer, 
has  well  repaid  the  practice.  Inasmuch  as  much  of  a 
thorough  annual  report  is  by  no  means  of  popular  interest 
and  would  be  wasted  upon  any  but  the  most  intelligent 
citizens,  the  value  of  the  popular  reprint  is  clear.     In  that 


554  A   MANUAL   FOR  HEALTH  OFFICERS 

town,  also,  a  pamphlet  entitled  "Rules,  Regulations  and 
General  Information  Concerning  Communicable  Diseases" 
has  been  printed  and  circulated  among  physicians,  medical 
inspectors,  teachers,  heads  of  families  and  nurses.  It  may 
be  added  that  in  this  instance  there  is  a  large  proportion  of 
intelligent  citizens  who  profit  by  such  literature  and  en- 
courage the  issuance  of  it. 

For  certain  specific  purposes  the  Issuance  of  special  cir- 
culars, posters,  etc.,  may  be  desirable.  Exhibitions  and 
campaigns  for  pure  milk,  against  the  spitting  nuisance,  for  a 
general  "clean-up,"  and  the  like,  demand  plenty  of  auxiliary 
printed  matter,  both  to  advertise  and  to  explain.^ 

For  some  purposes  posters  are  effective  and  may  be  dis- 
played in  store  windows,  on  public  bulletin  boards,  etc. 
The  Chicago  Department  of  Health,  for  example,  has  been 
successful  with  large  posters  (4  by  6  feet).  E\-en  the  bill- 
boards may  on  occasion  be  utilized,  as  has  been  done  in  the 
tuberculosis  campaign. 

Distribution.  —  The  question  of  distribution  will  natu- 
rally arise.  Bulletins  and  reports  are  frequently  sent  out 
on  a  mailing  list  comprising  (i)  citizens  and  local  officials 
who  will  benefit  by  them  and  (2)  a  selected  number  of 
"exchanges,"  i.e.,  interested  boards  of  health,  organizations 
and  individuals  in  other  municipalities.  A  local  list  may 
readily  be  started  by  means  of  the  ordinary  or  the  telephone 
directory.  For  certain  classes  of  matter  a  mail  distribution 
may  be  all  that  is  required.  The  labor  of  stamping  may  be 
avoided,  if  the  number  of  identical  pieces  of  mail  matter 
amounts  to  a  thousand  or  more,  by  taking  them  to  the  post- 
ofifice  in  bulk.     If,  however,  the  distribution  is  to  be  general 

*  Printed  matter  for  publicity  on  stock  subjects  may  be  obtained 
from  sources  mentioned  in  note,  p.  563;  also  from  Cameron,  Amberg, 
and  Co.,  15  West  Lai<e  St.,  Chicago,  and  Kirchner,  Mechel  and  Co., 
117  Nortii  5th  Ave.,  Chicago. 


i'Ui{i>i(i'i'Y  555 

and  (he  cost  of  postaj^c  (let  alone  addressing,  foMing,  in- 
serting, stamping  and  other  clerical  labor;  is  taken  intcj 
account,  house-to-house  distribution  is  cheaper.' 

For  certain  classes  of  circulars,  etc.,  the  health  officers 
may  be  able  to  obtain  distribution  by  volunteer  workers 
from  local  organizations. 

Circulars,  etc.,  may  often  be  most  advantageously  dis- 
tributed through  the  schools;  by  this  means  there  is  ob- 
tained a  wide,  though  not  universal,  distribution  at 
practically  no  expense.  In  obtaining  the  permission  of  the 
schools  a  statement  may  be  secured  showing  the  number  of 
pupils  in  each  room  and  the  circulars  may  then  be  delivered 
in  properly  counted  and  marked  bundles.  The  success  or 
failure  of  the  method  will  depend  upon  whether  or  not  the 
cooperation  of  the  school  authorities  is  obtained  to  such  an 
extent  that  the  necessity  of  taking  the  circulars  home  is 
impressed  upon  the  children.  After  some  experience  the 
writer  believes  that  under  the  best  conditions  the  great 
majority  of  the  circulars  will  reach  the  homes.  It  is  well 
to  print  in  heavy  type  at  the  top  of  the  sheet,  or  upon  an 
envelope  enclosing  the  matter,  the  legend  "To  be  Taken 
Home,"  or  something  similarly  impressive. 

The  publicity  technique  of  printed  matter  will  depend 
partly  upon  general  principles,  partly  upon  the  class  of 
persons  to  be  reached.  For  persons  who  will  read  and 
reason,  a  plain  piece  of  text  at  some  length  may  be  accept- 
able, but  this  class  is  usually  small  and  the  brief  statement 

1  In  Montclair,  N.  J.  (population  25,000),  approximately  1000 
annual  reports  and  3000  reprints  from  annual  reports  are  distributed 
by  the  house-to-house  method.  The  cost  is  $22  for  the  4000  copies 
($5.50  per  1000),  at  $2  per  man  per  day.  This  includes  ringing  each 
door-bell  and  handing  the  report  in.  It  is  intended  that  every  family 
shall  have  either  a  report  or  a  reprint.  "Our  reports  cost  3  cents  each 
to  mail.  If  they  cost  only  i  cent  distribution  by  messenger  is  cheaper, 
even  in  a  scattered  community  like  Montclair."  (Information  from 
C.  H.  Wells,  Health  Officer,  Montclair,  N.  J.) 


556  A  MANUAL   FOR  HEALTH   OFFICERS 

or  striking  cartoon  is  much  more  effective.  The  best  cir- 
cular or  poster  (unless  purely  of  the  cartoon  type,  which  is 
in  some  respects  the  most  useful  of  all)  is  a  combination  of 
text  and  pictorial  matter. 

///.    EXHIBITIONS' 

Of  recent  years  civic  exhibitions  have  been  growing  in 
favor  and,  among  them  not  only  general  public  health  ex- 
hibitions but  also  those  devoted  to  special  subjects,  such  as 
tuberculosis  or  milk  supply.  If  given  plenty  of  pul)licity, 
especially  through  press  notices  and  the  activities  of  strong 
cooperating  committees  of  citizens,  and  if  made  conspicuous 
by  striking  and  original  features  of  local  application,  ex- 
hibitions draw  large  crowds  and  start  waves  of  popular 
interest  as  scarcely  anything  else  can.  Moreover,  an 
impetus  is  given  for  a  steady  campaign,  which  may  —  as 
it  should  —  be  kept  up  long  after  the  exhibition  is  over. 
Aside  from  the  direct  educational  effect,  the  improved  pub- 
lic opinion  makes  adequate  health  funds  easier  to  obtain 
and  facilitates  administration.  There  is  no  better  way  for 
an  energetic  health  ofificer  to  start  a  campaign  for  general 
support,  or  for  some  special  object,  such  as  tuberculosis  or 
infant  hygiene  work  or  control  of  milk  supply,  than  this. 
There  are  few  towns  in  the  United  States  which  would  not 
be  benefited  by  a  good  health  exhibition. 

Such  an  exhibition  may  perhaps  take  place  in  connection 
with  a  "Health  Week"  as  has  been  conducted  in  Louis- 
ville, Ky.,  a  "Baby  Week,"  as  in  New  York,  and  the  like. 

Exhibitions  have  a  particular  advantage  in  that  they 
impress  various  kinds  of  persons:  the  literate  and  the  illiter- 
ate, the  intelligent  and  unintelligent;    even  the  unwilling 

^  By  an  "exhibition"  is  meant  a  more  or  less  extensive  display  having 
a  number  of  related  special  parts.  The  term  "exhibit"  is  reserved  for 
smaller  displays,  especially  those  limited  to  one  subject,  or  point.  Thus 
an  "exhibition"  would  be  composed  of  a  number  of  individual  "ex- 
hibits." 


I'lJi'.LicirY  557 

are  first  iiUcrestcd  and  ihcii  pt-rsuaflcd.  Almost  all  the 
various  modes  of  i)ul)ii(ity  may  be  pressed  inlf>  aetion: 
pictorial  posters,  photographs  and  diagrams  to  attract 
attention;  printed  placards,  literature  and  attendants  to 
explain;  all  kinds  of  models  and  mechanical  devices;  lec- 
tures, stereopticon  views  and  motion  pictures.  AH  of  these, 
combined  with  the  press  notices  which  are  sure  to  accom- 
pany a  good  exhibit,  constitute  a  veritable  battery  of 
publicity. 

PLANNING    AND    MANAGING    AN    EXHIBITION 

It  frequently  happens  that  inexperienced  persons  are  called  upon  to 
handle  exhibitions  and  that  much  time  is  wasted  in  preparation  and  much 
of  the  final  effect  lost  through  neglect  of  simple  though  not  always 
apparent  considerations.  In  fact,  shortcoming  in  a  single  important 
matter,  such  as  organization,  the  choice  of  a  location,  or  the  means  of 
publicity  may  impair  or  prevent  successes. 

Secure  Cooperation.  —  Let  us  suppose  that  the  health  officer  has 
decided  that  the  publicity  power  of  an  exhibition  is  needed  in  some  one 
or  in  all  departments  of  public  health  work  in  his  community.  How  is 
he  to  go  about  starting  a  campaign  for  that  object,  and  how,  in  outline, 
is  the  campaign  to  be  carried  out?  In  the  first  place  he  may  be  able  to 
persuade  his  board  that  an  exhibition  is  needed  and  to  obtain  from  the 
city  treasury  the  necessary  funds.  If,  however,  there  is  question  of 
this,  it  may  be  well  to  do  first  what  should  be  done  in  any  case,  —  secure 
the  interest  of  as  many  as  possible  prominent  and  public-spirited  citizens 
and  the  local  civic  societies.  The  cooperation  of  the  local  anti-tubercu- 
losis society,  visiting  nursing  association,  and  other  related  organiza- 
tions should  also  be  secured.  The  indispensable  value  of  cooperating 
citizen  committees  in  securing  prestige  and  publicity  will  be  mentioned 
again  later. 

Form  General  Committee.  —  Assumed  that  the  possibility  of  a 
successful  exhibition  has  been  assured,  the  first  step  will  be  the  forma- 
tion of  a  general  committee  of  influential  persons.  This  committee 
should  be  fairly  large,  and  even  if  some  of  the  members  furnish  no  more 
than  their  sanction,  it  forms  a  responsible  body  of  well-known  citizens 
who  will  lend  importance  and  dignity  to  the  project  and  plans  and  will 
obtain  the  cooperation  of  persons  who  are  desirable  for  the  associated 
committees  which  will  be  described  below.  Upon  the  latter  devolves 
responsibility  for  carrjdng  out  the  various  assigned  divisions  of  activity. 


558  A  MANUAL   lOR   IIKALTII  OFFICERS 

The  general  comiiiillcc  will  elect  its  chainnan,  who  should  be  a  promi- 
nent citizen  who  will  act  as  ijresiding  officer  but  not  director  of  the  work. 

Funds.  —  The  first  and  most  important  ciuestion  to  arise  will  then 
be  that  of  funds.  The  whole  scope  and  quality  of  the  exhibition  will 
necessarily  depend  upon  the  amount  of  money  which  can  be  raised  and 
expended.  Some  appropriation  can  perhaps  be  obtained  from  the 
board  of  health  or  municipal  council,  but  this,  especially  on  short  notice, 
would  not  be  likely  to  be  sufficient  for  an  adequate  exhibition.  Hence, 
subscriptions  from  private  persons  and  organizations  must  be  obtained. 
It  may  be  that  guarantees  can  be  obtaineil  without  delay  from  such 
sources  sufficient  to  insure  that  an  exhibition  on  the  scale  desired  can  be 
held;  or  a  committee  on  ways  and  means  ma>-  be  appointed  to  obtain 
subscriptions. 

Executive  Committee  and  Director.  —  As  soon  as  funds  are 
assured  an  executive  committee  should  be  appointed  (see  below  as  to 
composition).  This  committee  holds  frequent  meetings,  reporting  its 
plans  and  activities  to  the  general  committee  for  approval  from  time  to 
time.  It  is  here  that  the  driving  force  of  the  work  resides,  and  particu- 
larly in  its  chairman,  who  acts  virtually  as  executive  director.  This  part 
may,  perhaps,  though  not  necessarily,  be  taken  by  the  health  officer. 
At  any  rate  the  person  chosen  should  possess  executive  ability,  tact,  and 
good  taste,  and  should  be  thoroughly  acquainted  with  the  principles  of 
the  modern  public  health  movement.  It  would  be  a  vast  advantage 
in  those  places  which  can  afford  it  and  where  the  local  leaders  can  be 
led  to  appreciate  the  advantage,  to  employ  a  trained  professional  director. 
Not  only  the  training  of  such  an  expert  director,  but  also  his  outside 
point  of  view  is  an  advantage.  Even  where  such  a  director  cannot  be 
employed,  outside  expert  ad\-ice  is  of  great  value.' 

Cooperating  Committees.  —  These  should  be  formed  at  the  same 
time  as  the  executive.  It  is  best  to  form  each  of  these  under  the  chair- 
manship of  a  member  of  the  executive  committee.     The  latter  should 

^  The  Russell  Sage  Foundation  of  New  York  has  recently  organized 
a  Department  of  Surveys  and  Exhibits  having  as  one  of  its  chief  aims 
to  assist  communities  in  planning  and  executing  health  exhibitions,  an 
aim  which  had  earlier  been  adopted  by  the  Bureau  of  Municipal  Re- 
search of  New  York.  Both  of  these  have  a  national  scope  and  infor- 
mation and  ser^'ices  are  furnished  by  them  to  local  organizations.  The 
former  publishes  a  pamphlet  on  "Social  Welfare  P2xhibitions"  (price 
25  cents).  Addresses:  Sage  Foundation,  130  East  22nd  Street,  New 
York  City;  Bureau  of  Municipal  Research,  261  Broadway,  New  York 
City.  Valuable  hints  may  be  obtained  from  the  reports  of  the  Phila. 
Baby  Saving  and  Milk  Shows  (already  referred  to,  pp.  344,  395)- 


PUBLICITY  559 

be  no  larger  lliaii  is  necessary  lor  tliis  piirposct,  IjiiI  incinbers  may  be 
added  to  it  from  time  to  time  if  retiiiirerl.  It  would  i)erlia|)s  he  wise  to 
have  the  chairmen  of  the  coojierating  committees  report  and  confer  in 
informal  meetings  of  the  executive  committee  and  rejjort  only  occasion- 
ally in  a  formal  manner  to  the  general  committee.  In  this  way  the 
latter  would  be  kept  in  touch  with  the  actual  activities  going  on,  and 
could  give  its  general  a])proval;  though  after  the  start  its  position 
would  be  largely  formal. 

The  most  important  of  the  cooperating  committees  would  be  some- 
what as  follows:  Finance,  Publicity,  Hall,  Exhibits,  and  Xerogram.  The 
main  duties  of  these  committees  will  be  indicated  in  order  below.  It 
may,  of  course,  be  desirable  to  arrange  the  functions  somewhat  differ- 
ently or  to  subdivide  some  of  the  committees  above  suggested.  It 
would  be  well  to  get  as  many  persons  working  on  the  various  committees 
as  can  be  effectively  managed,  as  not  only  is  more  help  thus  obtained 
but  a  wider  circle  of  influence  in  attracting  publicity  is  the  result.  The 
whole  organization  should  be  as  elastic  and  adaptable  and  free  from 
unnecessary  formality  as  possible,  but  for  each  committee  and  each 
person  the  duties  would  be  very  clearly  defined. 

One  of  the  first  important  points  to  be  determined  by  the  general  or 
the  executive  committee  is  the  time  when  the  exhibition  is  to  be  held. 
Assuming  that  satisfactory  arrangements  for  location  can  be  made,  the 
dates  should  be  such  that  full  public  attention  can  be  secured,  free  from 
the  distraction  of  other  public  events  and  activities.  It  should,  more- 
over, be  some  weeks  in  advance,  so  as  to  allow  plenty  of  time  for  material 
to  be  collected,  worked  into  form,  and  set  up.  No  one  who  has  not  had 
to  do  with  the  preparation  of  even  a  small  exhibition  realizes  the  time 
and  labor  involved  in  the  production  of  first-class  exhibition  material, 
and  no  other  kind  should  be  invited.  Exhibits  are  likely  to  be  late  and 
accidents  may  occur,  but  eleventh  hour  hurrj'  should  be  avoided.  The 
duration  of  an  exhibit,  and  the  daily  hours,  may  constitute  a  question. 
Favorable  hours  are  12  to  10  P.M.  A  period  of  less  than  a  week  would 
scarcely  be  worth  while  for  any  exhibition;  a  longer  time  is  better. 
The  reason  for  this  is  that  during  the  first  few  days,  the  public  is  scep- 
tical, and  the  scepticism  can  only  be  broken  down  by  a  steadil}'  in- 
creasing attendance  and  the  interest  aroused  by  the  accounts  of  the 
press  and  of  the  early  spectators.  The  interest  will  usually  grow  up 
to  about  the  end  of  the  first  week  and  then  remain  for  some  days  at  a 
maximum. 

The  duties  of  the  finance  committee  (which  may  be  the  original  ways 
and  means  committee  continued)  require  no  special  comment. 

Publicity.  —  The  publicity  committee  has  functions  of  first  im- 
portance.    At  ever>^  stage  it  conducts  a  full  press  ser\-ice,  in  which  the 


560  A  MANUAL   FOR   HEALTH   OFFICERS 

cooperation  of  the  newspapers  may  be  counted  upon.  It  also  makes 
effective  use  of  the  other  modes  of  publicity,  such  as  public  bulletins 
and  posters,  handbills,  "sandwich  men,"  and  any  other  legitimate  and 
novel  de\'ices.  The  cooperation  of  the  schools  may  be  enlisted  and 
circulars  sent  out  by  distribution  to  the  pupils  with  the  instruction  to 
take  home.  Announcements  in  churches,  clubs,  labor  organizations, 
lodges,  etc.,  may  be  requested.  The  exact  time  and  hours  of  the  ex- 
hibition should  be  emphasized  and  it  should  be  made  evident  that 
everybody  is  expected  and  that  a  large  attendance  is  expected.  An 
important  point  at  the  time  of  the  exhibition  is  to  have  the  approaches 
and  entrance  well  placarded.  The  publicity  committee  will  have  plenty 
of  opportunity  for  the  exercise  of  activity  and  imagination. 

Location  and  Hall.  —  The  committee  on  hall  will  find  a  place  for 
the  exhibition  to  be  held  and  make  all  arrangements  (e.g.,  cleaning, 
heating,  lighting)  in  connection  therewith.  This  may  be  determined 
somewhat  by  space  requirements  (see  below).  It  is  essential,  however, 
to  secure  a  place  where  people  are  accustomed  to  go  and  where  they  will 
find  it  easy  to  go.  An  assembly  hall,  armory  or  part  of  a  school  may 
serve  well,  provided  it  has  a  prominent  location  near  the  business  center 
of  the  town.  It  should  be  on  the  ground  floor,  or  at  least  not  higher 
than  one  flight  up,  and  the  entrance  should  be  large  and  conspicuous. 
A  sufficiently  large  empty  store  is  very  favorable.  It  should  be  possible 
to  find  a  place  of  one  of  these  kinds  where  no  charges,  or  only  very 
moderate  charges  for  light  and  janitor  service,  need  be  paid. 

A  common  mistake  is  to  secure  too  little  space,  resulting  in  a  cramped 
exhibition  "viewed"  by  a  swarm  of  hot  and  irritated  spectators  worm- 
ing their  way  through  congested  aisles  and  corners.  Even  leaving  out 
of  account  esthetic  considerations,  the  demands  of  ventilation  make 
full  space  a  prime  desideratum.  There  is  little  danger  of  getting  too 
much;  the  amount  of  wall  area  which  an  exhibition  may  be  extended 
to  cover  with  good  efi'ect  is  surprising.  Proper  grouping  will  prevent  a 
straggling  appearance,  but  nothing  can  obviate  the  sense  of  confusion 
produced  by  crowding  even  well  composed  exhibits.  Better  a  fully 
spaced  though  comparatively  limited  exhibition  than  a  more  preten- 
tious one  injured  by  serious  cramping. 

Another  consideration  is  that  there  shall  be  an  auditorium,  or 
a  space  where  a  platform  and  hired  chairs  can  be  placed,  for  the 
addresses  to  be  held  in  connection  with  the  exhibition.  Special  ar- 
rangements are  also  usually  necessary  for  erecting  and  operating  a 
stereopticon  or  motion  picture  machine.  Gas  or  electricity  must  be 
looked  after  and  legal  regulations,  if  any,  ascertained. 

Exhibits.  —  To  the  exhibit  committee  belongs  responsibility  for  the 
composition  and  arrangement  of  the  exhibition  as  a  whole.     It  must 


PUBLICITY  561 

naturally  work  in  close  toiicii  willi  dircclor  and  lif.iltli  oflirfr.  It.  has 
to  make  the  necessary  arran^eineiils  for  ohtainiiij;  cxhiliits  from  various 
sources,  when  necessary,  advising  the  planners  of  the  individual  exhibit. 
The  lader  in  their  turn  should  see  that  the  material  to  he  [iresentcd  is 
put  in  proper  form  througli  the  services  of  drauj,ditsmen,  photographers, 
and  sign-painters;  amateur  work  in  these  lines,  unless  expert,  is  ineffec- 
tive. 

There  should  be  kept  constantly  prominent  by  the  director  and  ex- 
hibit committee  a  well-proportioned  plan  for  the  exhibition  as  a  whole, 
into  which  the  various  groups  shall  fit  harmoniously  and  in  proper 
degrees  of  emphasis. 

In  order  to  insure  orderly  and  timely  installation  certain  definite 
rules  should  be  adopted,  e.g.: 

(i)  That  each  organization  or  department  contributing  be  assigned 
a  definite  amount  of  space  proportioned  to  the  importance  of  that 
organization. 

(2)  That  a  definite  date  be  set  when  all  exhibits  are  to  be  in  place; 
say  two  days  before  the  public  opening. 

Through  tactful  conference  with  those  furnishing  material  it  should 
be  so  far  as  possible  edited  both'  as  to  content  and  as  to  form.  The 
great  difficulty  with  all  exhibitions  is  to  know  what  to  leave  out.  The 
material  at  the  disposal  of  the  exhibitor  is  so  great  and  all  seems  to  him 
to  be  so  important  that  there  is  an  almost  irresistible  tendency  on  the 
part  of  the  inexperienced  to  include  too  much.  Too  many  facts  are 
worse  than  too  few,  for  the  latter  situation  is  at  least  in  accord  with  the 
psychological  principle  of  publicity  that  only  a  very  few  facts  can  be 
presented  at  a  time.  Spectators  find  exhibits  tiring  and  confusing 
on  account  of  the  excessive  amount  of  material  displayed  and  find  it 
impossible  to  make  the  round  properly  in  the  limited  time  at  their 
disposal.  It  may  be  taken  as  an  axiom,  therefore,  that  only  tlie  Jew 
essential  points  should  be  presented  and  those  as  vividly  and  simply  as 
possible.  In  the  long  run  quality'  will  count  strongly,  while  quantity  is 
only  a  hindrance.  Detailed  information,  it  is  to  be  remembered,  may 
be  always  available,  in  the  form  of  circulars,  reports,  etc.  But  to  pre- 
sent everything  that  is  merely  presentable,  through  a  mistaken  sense 
of  proportion,  is  a  fatal  error,  and  a  vast  waste  of  time  and  labor. 

Exhibits  are  much  enhanced  in  value  through  the  presence  of  demon- 
strators or  explainers  to  draw  attention  to  them,  explain,  answer  ques- 
tions and  give  out  literature.  Arrangements  should  be  made  for  the 
services  of  such  persons  at  the  most  important  exhibits,  at  least  at  the 
hours  of  greatest  attendance.  For  this  purpose  a  schedule  for  the  volun- 
teer services  of  members  of  societies  and  other  interested  persons  may 
be  arranged.  ' 


562  A   M/VNUAL   FOR   HI-:ALriI    Ol'FICERS 

.  Program.  —  The  iwogram  committee  plans  and  makes  all  arrange- 
ments for  the  addresses  and  lectures  to  be  given  during  the  course  of  the 
exhibition.  It  is  assumed  that  the  hall  committee  has  arranged  a  suit- 
able auditorium  or  space  of  sufficient  size  where  an  audience  may  be 
accommodated.  In  composing  the  program  both  its  aUractiveness  and 
its  educative  value  should  be  considered.  It  is  good  policy  to  obtain 
addresses  by  the  Mayor  and  prominent  citizens,  or,  better,  have  one  such 
person  preside  at  each  session,  the  Mayor,  if  possible,  on  the  opening 
night.  The  president  of  the  local  board  of  health,  the  health  officer, 
prominent  physicians  and  others  may  be  includetl.  If  at  all  possible 
addresses  by  public  health  experts  from  outside  the  community  should 
be  secured,  these  carrying  special  weight.  Addresses  shoukl  be  brief,  — 
say  not  over  five  or  ten  minutes  except  for  the  main  lecture  of  the  even- 
ing; even  the  latter,  however,  should  be  limited  if  possible  to  half  an 
hour.  We  speak  here  of  the  actual  time  consumed,  which  always,  as 
explained  below,  exceeds  that  literally  allowed.  In  general,  in  view  of 
the  necessity  of  allowing  time  for  the  exhibit  to  be  viewed,  the  audience 
should  not  be  expected  to  remain  in  the  seats  over  an  hour.  Agree- 
ment should  be  made  with  each  speaker  as  to  the  time  he  is  to  occupy, 
so  as  to  do  justice  to  the  others  on  the  program.  Speakers  are  very 
prone  to  run  over  time,  and  to  correct  this  tendency,  instead  of  endeavor- 
ing to  enforce  a  strict  rule,  it  is  better  to  assign  each  speaker  a  very 
limited  time  on  the  unexpressed  assumption  that  he  is  almost  certain  to 
excess  it  more  or  less.  Thus  "ten-minute"  speeches  almost  always  last 
fifteen  or  twenty  minutes,  "fifteen-minute"  ones  nearly  half  an  hour, 
and  so  on,  and  a  session  which  figures  up  on  the  program  to  three- 
quarters  of  an  hour  will  actually  run  to  something  over  an  hour,  even  if 
there  is  no  discussion. 

A  good  arrangement  is  to  devote  each  session  to  a  special  subject  or 
limited  group  of  subjects,  with  a  main  address  by  a  prominent  speaker 
preceded  by  brief  addresses  by  several  others.  The  latter  may  be  five- 
or  ten-minute  speeches.  A  lecture  illustrated  with  stereopticon  or  a 
motion  picture  exhibition  forms  an  especially  good  main  "feature"  for 
a  session.  Subjects  may  be  subdivided  or  combined  to  fit  the  number 
of  sessions  or  addresses  which  can  be  devoted  to  them.  Distinction 
should  be  made  between  the  afternoon  and  evening  sessions;  com- 
paratively few  adults  will  be  able  to  attend  the  former  and  hence  they 
may  perhaps  be  used  for  prearranged  visits  of  groups  of  school  children, 
for  whom  no  formal  or  extensive  program,  possibly  only  a  brief  illus- 
trated lecture,  is  required.  If  various  nationalities  are  represented  in 
the  community  another  arrangement  of  the  program  is  possible,  allow- 
ing a  special  night  for  each  of  the  important  ones.  Other  population 
groups  may  also  be  arranged  for,  especially  in  an  industrial  community. 
Further  remarks  on  lectures  will  be  made  in  a  later  section. 


PUBLICI'I'Y  56.3 

Special  Exhibition  Material.  -  Sonic  of  tlic  best  rx- 
hibition  work  can  be  done  by  means  of  rcnU'd  fjr  borivjwcfl 
material  from  HjK'cial  sources.  When  such  material  is  used 
a  great  deal  of  kx.al  planning,  labor  and  expense  can  be 
saved. ^  Very  useful  small  exhibits  (see  next  section)  can 
also  be  thus  obtained.  Local  health  ofificers  can  do  a  great 
deal  to  further  the  health  exhibition  movement  by  inducing 
their  state  departments  of  health  to  provide  traveling  ex- 
hibits, and  by  approaching  the  extension  departments  of 
their  state  universities  with  a  similar  object.  Some  of  the 
latter,  particularly  in  the  upper  Mississippi  Valley,  are 
already  taking  up  social  welfare  and  health  exhibition  work. 
Groups  of  towns  or  cities  could  also  work  up  a  cooperative 
arrangement,  each  one  developing  an  exhibit  dealing  with 
some  special  subject,  these  to  be  interchanged  among  them. 
All  arrangements  by  which  the  same  material  can  be  utilized 
repeatedly  by  various  communities  make  it  possible  to 
produce  the  highest  grade  of  exhibits  at  the  minimum  of 
cost.  Economy  may  also  be  practiced  by  getting  models 
and  devices  and  cartoons  prepared  by  local  manual  training 
or  art  schools  and  by  other  organizations  or  persons  who  are 
interested.  A  good  idea  of  the  kind  of  material  used  in 
health  exhibitions  may  be  gained  by  a  visit  to  those  acces- 
sible in  New  York,  Chicago  and  other  large  cities.^  Sug- 
gestions may  also  be  gathered  from  the  reports  of  the 
Philadelphia  Milk  Show  and  Baby  Saving  Show.^ 

^  Such  material  can  be  obtained  from:  the  Department  of  Health, 
Chicago;  Am.  Assn.  for  Prevention  of  Infant  Mortality,  121 1  Cathedral 
St.,  Baltimore;  Dept.  of  Child  Helping,  Sage  Foundation,  130  East 
22nd  St.,  New  York  City;  Nat.  Child  Welfare  Exhibition  Committee, 
200  Fifth  Ave.,  New  York  City;  Nat.  Assn.  for  Study  and  Prevention 
of  Tuberculosis,  105  East  22nd  St.,  New  York  City;  and  other  national 
health  organizations;  also  from  the  Educational  Exhibition  Co.,  26 
Customhouse  St.,  Providence,  R.  I. 

^  List  of  these  will  be  supplied  on  application  to  Dept.  Surv^eys  and 
Exhibits,  Sage  Foundation,  130  East  22nd  St.,  New  York  City. 

3  See  pp.  344  and  395. 


564  A  MANUAL   FOR  HEALTH  OFFICERS 

IV.  SMALL  EXHIBITS 

In  many  cases,  especially  in  small  towns,  it  may  not  be 
possible  to  work  up  an  exhibition  on  the  scale  suggested 
above.  In  such  instances  the  use  of  single  exhibits  is 
highly  to  be  recommended,  and  under  any  circumstances 
it  is  desirable  that  the  health  department  have  constantly 
one  or  more  such  exhibits  on  view.  It  is  possible  for  prac- 
tically every  health  department  to  make  up,  or  purchase 
or  hire  from  one  of  the  sources  given  above,  one  or  more 
simple  but  effective  exhibits  which  can  be  set  up  in  vacant 
stores,  store  windows,  schools  and  other  places  in  the  public 
view.  In  the  larger  towns  such  exhibits  may  be  moved 
occasionally  to  a  new  place  so  as  to  attract  the  notice  of  a 
different  portion  of  the  public. 

Again,  it  not  infrequently  happens  that  a  fair  or  local 
exposition  affords  an  opportunity  for  the  health  department 
to  take  part.  Thus,  if  the  chamber  of  commerce  or  busi- 
ness men's  association  holds  a  local  fair  or  industries  expo- 
sition it  will  often  be  possible  for  the  health  officer  to  obtain 
an  exhibition  booth  rent-free.  Such  opportunities  occur 
from  time  to  time  in  a  great  many  towns. 

Small  exhibits  may  consist  in  models,  charts  or  demon- 
stration material.  As  to  subjects,  instead  of  trying  to 
cover  the  subject  of  public  health  in  a  general  way,  the 
aim  should  be  to  present  one  seasonable  idea  at  a  time,  and 
even  to  use  only  a  single  effective  model,  chart,  cartoon 
or  device.^ 

V.  LECTURES 

The  progressive  health  officer  will  frequently  be  called 
upon  to  deliver  lectures,  addresses  and  talks  before  more  or 
less  influential  civic  and  philanthropic  bodies  and  before 
popular  audiences.  There  is  only  one  important  caution 
about  accepting  such  invitations:   be  sure  that  the  audience 

1  Such  ma>-  be  purchased  or  hired  if  desired.  See  preceding  section 
and  note,  p.  563. 


PUBLICITY  565 

will  be  worth  the  effort  and  publicity  entailed.  It  is,  there- 
fore, discreet  to  choose  only  the  best.  Time  and  energy 
may  be  consumed  addressing  very  minor  organizations, 
which  could  better  be  concentrated  on  a  few  occasions  to 
deliver  definite  "messages"  which  will  have  wide  publicity 
and  influence.  Better,  in  short,  half  a  dozen  imjjortant 
speeches  a  year  than  several  dozen  minor  ones. 

While  the  health  officer  is  the  natural  leader  of  all  dis- 
cussion on  public  health  topics,  addresses  by  the  president 
of  the  board  of  health,  the  mayor  and  other  prominent  and 
well-informed  physicians  or  laymen  are  frequently  useful. 

Methods.  —  A  public  speech  cannot  be  too  carefully  pre- 
pared, and  the  speaker  should  be  ready  to  have  searching 
questions  put  to  him.  A  good  short  address  without  the 
use  of  notes  is  usually,  perhaps,  most  impressive.  On  the 
other  hand,  if  an  effective  speech  cannot  be  so  deliv- 
ered, it  is  better  to  write  out  and  speak  (not  merely 
read)  from  the  manuscript.  Clear  and  simple  charts,  dia- 
grams, photographs  and  models  may  serve  in  lieu  of  notes, 
and  the  same  purpose  is  served  by  the  lantern  views  of  an 
illustrated  lecture.  These  accessories  are  also  frequently 
desirable  to  make  one's  meaning  clear  and  to  interest  and 
impress  the  audience. 

The  principle  already  mentioned — that  only  a  few  points 
should  be  taken  up  and  these  treated  in  a  vivid  manner 
and  illustrated  by  striking,  even  humorous,  examples  — 
applies  to  public  addresses,  as  well  as  do  the  other  basic 
principles  of  publicity.  Rarely  should  an  address  be  over 
a  half-hour  in  length  (illustrated  lectures  excepted),  and 
a  quarter-hour  concentrated  upon  one  or  two  important 
topics  is  sometimes  even  better,  especially  when  there 
are  other  speakers  on  the  program.  Even  at  that  the 
speaker  has  an  opportunity  to  deliver  about  2000  words  — 
if  newspaper  columns  or  three  times  as  many  words  as 
the  editorials  of  metropolitan  dailies  devote  to  the  prin- 
cipal  topics   (without   taking  into  account  the  fact  that 


566  A  MANUAL   FOR   HEALTH   OFFICERS 

one  reads  about  twice  as  fast  as  the  public  speaker  speaks). 
There  is  a  tendency  on  the  part  of  all  speakers  to  run  over 
time,  a  ten-minute  speech  becoming  fifteen  or  twenty 
minutes,  a  fifteen-minute  speech  half-an-hour,  etc.  Hence, 
the  caution  is  in  order  never  to  run  over  the  allotted  time.  For 
inexperienced  speakers  (and  some  experienced  ones  as  well) 
the  hint  to  speak  somewhat  slowly  and  distinctly  may  often 
be  of  value.  It  is  advisable  to  bring  out  clearly  in  the  open- 
ing words  the  subject  of  the  discourse,  and  in  the  closing 
words  to  draw  together  the  points  to  be  emphasized. 

In  passing,  a  word  may  be  said  as  to  statistical  and  other 
data.  It  is  necessary  for  the  health  officer  to  have  such 
facts  near  the  tongue's  end  for  ready  reference  at  any  time. 
While  the  quoting  of  "round  figures"  has  its  dangers,  neither 
is  it  necessary  to  memorize  columns  of  figures  which  weary 
both  speaker  and  hearer.  What  the  public  desires  and 
understands  is  not  detailed  statistical  analysis  but  a  few 
definite,  accurate  figures  which  can  be  simply  stated  with- 
out "about's"  and  "  approximately 's." 

As  to  publicity,  press  notices  are  especially  important, 
not  only  before  but  also  after  the  event.  In  order  to  guard 
against  misquotation  and  to  insure  a  good  press  account, 
the  speaker  should  if  possible  prepare  a  draft,  at  least  in 
outline,  of  his  address  and  furnish  to  the  newspapers  several 
days  beforehand  "advance"  copies  marked  with  a  memo- 
randum of  the  date,  hour  and  place  of  delivery.  The  fact 
that  an  address  is  delivered  to  only  a  comparatively  small 
number  of  people  is  thus  compensated  for  by  the  wide  cir- 
culation given  by  the  press  to  even  a  portion  of  the  matter 
delivered. 

The  use  of  lantern  slides,  charts,  etc.,  in  lectures  is  an 
especially  important  consideration.  The  value  of  such 
material  depends  upon  its  choice  and  the  method  of  use. 
Such  illustrations  should  not  only  be  strictly  appropriate 
to  the  particular  use  that  is  made  of  them,  but  should  also 
be   fully   explained.     Too   rapid   exhibition   may   interest 


pun  LICIT  Y  567 

the  audience  without  allowing  sufficient  time  for  explana- 
tion of  each  point  by  the  lecturer  and  its  comprehension 
by  the  audience.  In  short,  the  lecturer  should  not  make 
his  remarks  a  mere  passing  commentary  on  the  illustrations 
but  should  rather  use  them  as  texts  for  his  discussion. 
Thus  comparatively  few  slides  or  charts,  if  to  the  point, 
need  be  used.  Their  order  should  be  carefully  planned,  so 
that  a  logical  sequence  may  be  obtained. 

Good  lantern  slides,  separately  or  in  sets,  may  now  be 
obtained  at  a  moderate  cost,  or  the  lecturer  may  have  slides 
made  from  his  own  material  by  the  firms  specializing  in 
their  manufacture.^  Lantern  slides  should  be  technically 
perfect,  and  good  plain  slides  are  better  than  inferior  colored 
ones. 

VI.  MOTION  PICTURES 

The  influence  of  motion  pictures  is  obviously  wide,  and 
their  impressiveness  from  a  psychological  point  of  view 
great.  There  is  now  a  wide  range  of  educational  films  upon 
the  screens  and  among  them  a  number  which  deal  with 
public  health  subjects,  e.g.,  tuberculosis,  unsanitary  work- 
ing conditions,  typhoid  fever,  etc.  The  managers  of  moving 
picture  theatres  frequently  have  lists  of  such  films  ^  and  are 
usually  glad  to  obtain  and  show  them  as  a  regular  part 
of  their  performance  if  the  health  department  or  other 
organization  will  give  them  some  publicity.  With  the  more 
extensive  development  of  small-size  motion  picture  appa- 
ratus for  schools,  clubs,  lodges  and  other  similar  audiences, 
this  form  of  publicity  will  become  increasingly  a\-ailable. 

Motion  pictures  have,  however,  certain  limitations.  It 
must  not  be  supposed  that  they  can  satisfactorily  displace 
any  other  method.     As  an  attraction  their  value  is  high, 

'  For  information  as  to  the  various  sources  of  such  material  apply 
to. the  Dept.  of  Surveys  and  Exhibits,  Sage  Foundation,  130  East  22nd 
St.,  New  York  City. 

^  Or  apply  to  Sage  Foundation  {supra). 


568  A   MANUAL   FOR   HEALTH   OFFICERS 

but  a  disadvantage  lies  in  the  fact  that  very  little  explana- 
tory matter  can  go  with  them  on  the  screen  and  practically 
none  at  all  by  word  of  mouth.  They  are  based  on  action, 
and  a  great  many  important  facts  can  be  conveyed  by  action 
in  only  a  roundabout  way  or  not  at  all.  It  seems  to  the 
author  that  the  educational  —  as  distinguished  from  the 
attractional  —  value  of  this  form  of  entertainment  tends 
to  be  overrated.  It  must  also  be  remembered  that  it  is 
difficult,  expensive  or  impossible  to  arrange  for  moving 
pictures  in  many  places  where  other  effective  forms  of 
publicity  are  more  readily  available. 

PUBLICITY  AND  ADMINISTRATION 

While  wise  and  persistent  publicity  will  accomplish  much, 
wc  cannot  close  the  subject  without  a  caution  as  to  its 
limitations.  It  must  be  remembered  that  there  are  great 
numbers  of  people  who  are  not  affected  —  or  are  affected 
only  remotely  —  by  publicity,  and  that  the  sanitary  edu- 
cation of  the  masses  is  a  limited  and  gradual  process. 
Publicity  can,  in  fine,  only  facilitate  or  supplement  admin- 
istration, not  supply  a  substitute  for  it. 

On  the  other  hand,  apart  from  the  question  of  permanent 
educational  effects,  publicity  has  a  direct  and  immediate 
value  in  stimulating  public  opinion  to  a  sense  of  community 
health  needs,  thus  conducing  to  adequate  funds  and  moral 
support. 


APPENDIX   A 

DISINFECTION  AND   DISINFECTANTS^ 
TERMS 

Disinfection  is  the  process  of  destroying  pathogenic  (disease-produc- 
ing) microorganisms.  It  does  not  necessarily  mean  the  destruction  of 
all  microorganisms  —  which  is  sterilization.  Absohite  sterilization  is 
not  usually  necessary  in  public  health  practice;  efficient  disinfection 
destroys  the  harmful  organisms,  while  those  remaining  arc  for  the  most 
part  hardy  but  harmless  forms,  the  destruction  of  which  is  impracticable 
and  unnecessary.  Only  in  the  case  of  a  few  infections  —  e.g.,  anthrax 
and  tetanus  —  which  have  resistant  spores  is  absolute  sterilization 
necessary.  It  is,  however,  sometimes  desirable  to  require  practically 
complete  sterilization  (e.g.,  of  milk  utensils)  in  order  to  insure  that 
there  is  thorough  disinfection. 

Agents,  physical  or  chemical,  which  disinfect  are  called  disinfectants. 
Those  which  destroy  germs,  without  reference  to  their  character,  are 
called  germicides,  a  term  frequently  used  interchangeably  with  the 
other. 

There  is  another  class  of  substances  known  as  antiseptics.  These 
simply  retard  or  prevent  the  growth  and  activity  of  microorganisms 
without  necessarily  destroying  them.  In  other  words  they  hinder  or 
prevent  "sepsis"  (bacterial  fermentation).  Thus  a  minute  quantity 
of  formalin  (say  i  to  50,000)  will  prevent  the  development  of  bacteria, 
but  it  requires  a  much  greater  quantity  (3  to  5  per  cent)  actually  to 
kill  the  bacteria  within  a  reasonably  short  time.  In  the  former  in- 
stance the  formalin  is  used  as  an  antiseptic,  in  the  latter  as  a  germicide 
(or,  if  infectious  disease  organisms  are  present,  as  a  disinfectant). 

Asepsis  is  a  state  of  freedom  from  living  microorganisms.  Thus  a 
process  of  sterilization  results  in  a  condition  of  asepsis,  which  may  be 
maintained  indefinitely  by  excluding  all  germs.  In  this  sense  we  speak 
of  aseptic  methods  in  surgery. 

A  class  of  substances  quite  distinct  from  the  above  are  the  deodor- 
ants, which  destroy  or  neutralize  odors  due  to  putrefaction,  etc.  Many 
of  the  disinfectants  are,  as  it  happens,  also  deodorants,  but  the  popular 
impression  that  deodorants  are  always  disinfectants  is  incorrect,  for  only 

1  For  general  remarks  as  to  the  value  and  modes  of  employment  of 
disinfection  see  Part  II,  Chapter  I,  pp.  123  f.,  131  fT. 

569 


570  A   MANUAL   FOR   HEALTH   OFFICERS 

in  certain  instances  is  this  the  case.  Charcoal,  for  example,  absorbs 
odors,  but  exerts  no  disinfectant  or  germicidal  power.  On  the  other 
hand  bichloride  of  mercur>'  acts  as  a  germicide  without  removing  odors. 
Formalin,  however,  is  an  example  of  a  substance  which  possesses  both 
properties.  The  term  deodorant  does  not,  it  may  be  noted  in  passing, 
pro[)erly  apply  to  those  strong-smelling  substances  which  merely  mask 
one  odor  with  another. 

DISINFECTANTS 

For  removing  or  destroying  the  danger  of  infectious  material  the 
best  agents  are  those  which  are  simplest  and  nearest  to  hand:  cleanli- 
ness and  heat  in  its  various  forms.  Too  much  stress  has  in  the  past 
been  placed  upon  chemical  disinfectants,  which  are  not  always  readily 
available,  which  are  frequently  ineffectively  applied,  and  which  are 
often  powerful  poisons.  To  prepare  disinfectant  solutions  requires  a 
degree  of  intelligence  which  cannot  always  be  expected,  but  any  house- 
wife can  apply  soap  and  water  and  either  burn  up  infected  objects  and 
materials  or  simply  boil  them  on  the  stove.  Except  for  the  disinfec- 
tion of  excreta  and  the  care  of  the  nurse's  hands,  there  is  little  need 
for  chemical  disinfectants,  which  are  only  too  often  used  to  ward  ofT 
the  dangers  of  carelessness  and  uncleanliness. 

The  following  descriptions  are  by  no  means  exhaustive;  rather  is 
stress  laid  on  the  simpler  methods  which  may  be  readily  applied  in 
any 'household. 

The  value  of  cleanlmess  —  particularly  of  personal  cleanliness  — 
as  a  prophylactic  measure  cannot  be  too  strongly  insisted  upon.  While 
only  a  part  of  the  dirt  ordinarily  met  with  may  be  the  vehicle  of  infec- 
tion, nevertheless  decency  and  prudence  bid  that  all  filth  be  treated 
with  the  same  abhorrence.  And  this  has  reference  particularly  to  the 
transference  of  even  small  amounts  of  secretions  and  discharges  from 
person  to  person.  If  cleanliness  in  this  sense  were  maintained  by  all 
persons  certain  communicable  diseases  would  be  practically  wiped 
out.  If  such  cleanliness  were  maintained  in  the  .sick-room  the  need 
for  chemical  disinfection  would  be  much  lessened.  But  owing  to 
popular  ignorance  as  to  modes  of  infection,  possible  carelessness,  and 
the  practical  obstacles  to  an  ideal  degree  of  cleanliness,  the  additional 
safeguard  of  disinfectants  is  relied  upon  to  prevent  infection  from 
known  cases  of  communicable  disease. 

PHYSICAL  AGENTS 

In  nature  there  are  various  agents,  e.g.,  sunlight,  desiccation,  extreme 
heat  and  cold,  etc.,  which  tend  to  diminish  greatly  the  pathogenic 
organisms  at  large.  It  is  the  part  of  sanitary  science  to  utilize  so  far 
as  possible  these  natural  means. 


APPENDIX   A  571 

Sunlight  has  a  certain  germicidal  effect.  Practically,  however,  it 
can  only  be  utilized  as  supplementary  to  the  usual  methods.  Rooms 
and  articles  which  have  i)cen  disinfected  should,  whenever  possible,  be 
exposed  to  fresh  air  and  sunlight. 

Heat  is  a  highly  efficient  and  practical  disinfectant  agcni.  It  may 
be  applied  either  dry  or  moist.  Assuming  the  temperature  is  the 
same  in  both  cases  moist  heat  is  more  effective. 

The  simplest  application  of  dry  heat  is  by  means  of  burninf^,  and 
many  articles  such  as  cloths,  rags,  papers,  sputum  cups  and  others  of 
little  or  no  value  are  best  burned  up. 

The  simplest  application  of  moist  heat  is  by  boiling.  This  methofl 
is  available  in  practically  all  households  and  highly  to  be  recommended. 
Bed  linen,  personal  linen,  eating  utensils  and  other  washable  articles 
are  thus  most  readily  and  surely  disinfected.  Moist  heat  of  60°  C. 
(140°  F.)  for  20  minutes  will  destroy  the  microorganisms  of  cholera, 
typhoid  fever,  dysentery,  diphtheria,  plague,  tuberculosis,  pneumonia, 
erysipelas  and  practically  all  non-spore-bearing  bacteria'  (Rosenau). 
Boiling  kills  them  at  once,  but  should  be  prolonged  for  some  minutes 
in  order  to  insure  penetration. 

Dry  heat  is  effective  but  is  not  as  satisfactory  as  moist  heat  for  the 
reasons  that  it  lacks  power  of  penetration  and  is  injurious  to  fab- 
rics. A  temperature  of  150°  C.  for  one  hour  will  destroy  all  forms  of 
life,  even  the  most  resistant  spores.  "The  ordinary  household  cook- 
ing oven  is  as  good  as  any  specially  contrived  apparatus  for  the  disin- 
fection of  small  objects  by  dry  heat.  In  the  absence  of  a  thermometer 
it  is  usual  to  heat  the  oven  to  a  point  necessary  to  brown  cotton  and 
expose  the  objects  no  less  than  one  hour"  (Rosenau). 

'  The  bacilli  of  anthrax  and  tetanus  form  hardy  spor^  which  resist 
the  ordinary  methods  of  disinfection,  though  as  a  rule  (not  invariably) 
they  are  killed  in  streaming  steam  or  boiling  water  in  60  minutes. 
"Tetanus  [and,  since  their  resisting  powers  are  about  the  same,  an- 
thrax] spores  resist  the  action  of  5  per  cent  carbolic  acid  for  10  hours, 
but  are  killed  in  15  hours.  A  five  per  cent  solution  of  carbolic  acid, 
however,  to  which  0.5  per  cent  of  hydrochloric  acid  has  been  added, 
destroys  them  in  2  hours.  Bichloride  of  mercury,  i  to  1000,  kills  the 
spores  in  3  hours,  and  in  30  minutes  when  0.5  per  cent  of  hydrochloric 
acid  is  added  to  the  solution.  .  .  .  Tetanus  [and  anthrax]  spores  are 
destroyed  with  certainty  when  exposed  to  dry  heat  at  or  above  160°  C. 
for  one  hour,  or  to  steam  at  120°  C.  for  20  minutes."  (Rosenau,  "  Pre- 
ventive Medicine  and  Hygiene,"  1913,  p.  71.)  Organic  matter  hinders 
the  effect  of  chemical  disinfectants,  which  must  be  used  in  e.xcess  in 
its  presence  (see  p.  576).  For  the  disinfection  of  hides  for  anthrax 
see  p.  251.  Fortunately  the  health  officer  has  to  deal  with  these 
organisms  but  seldom. 


572  A   MANUAL    FOR    HEALTH    OITTCERS 

The  above  arc  methods  readily  apiilicahle  in  any  household.  In 
the  laborator>'  and  under  other  special  conditions  it  is  feasible  to  make 
use  of  special  apparatus  and,  furthermore,  of  a  most  valuable  agent 
—  steam.  Steam  is  quick,  reliable  and  penetrates  deeply.  Further, 
it  does  more  than  disinfect;  with  the  few  exceptions  already  noted,  it 
sterilizes. 

Either  streaming  steam  or  steam  under  pressure  may  be  used. 
The  former  is  the  principle  utilized  in  the  .Arnold  steam  sterilizer  or 
the  Koch  steamer  in  the  laboratory.  When  steam  is  held  under 
pressure  its  temperature  increases  and  it  becomes  very  highly  effective 
as  a  sterilizing  agent.  This  fact  is  made  use  of  in  the  laboratory 
digestor  or  autoclave  and  in  the  larger  steam  disinfecting  chambers. 

Rosenau  •  states  that  "streaming  steam  has  the  same  disinfecting 
power  as  boiling  water,  and  an  exposure  of  half  an  hour  to  an  hour  is 
sufficient.  ...  At  a  pressure  of  15  pounds  to  the  square  inch  steam 
has  a  temperature  of  approximately  120°  C.  and  may  be  depended 
upon  to  sterilize  in  20  minutes.  At  20  pounds  pressure  it  has  a  tem- 
perature of  approximately  125°  C.  and  will  sterilize  in  15  minutes." 

CHEMICAL  AGENTS 
A.   Liquid  Disinfectants 

Various  chemical  substances  are  used,  either  in  solution  or  in  sus- 
pension, as  disinfectants.  We  can  here  mention  only  the  more  im- 
portant and  their  chief  modes  of  employment.  The  effect  of  organic 
matter  in  lessening  the  effects  of  disinfectants  must  be  borne  in  mind 
(see  p.  576). 

Lime  is  a  cheap  and  efficient  germicide.  Lime  mixtures  must,  how- 
ever, be  made  from  freshly  burned  quicklime,  for  the  reason  that  lime 
in  any  form  loses  its  disinfectant  power  on  standing  in  contact  with 
air,  by  being  converted  into  calcium  carbonate,  which  has  no  germi- 
cidal property.  Since  lime  is  cheap,  it  may  be  used  freely  so  as  to  in- 
sure thorough  action. 

Convenient  Formula  ^ 

(Milk  of  Lime) 

Slake  a  quart  of  freshly  burned  lime,  in  small  pieces,  with  three- 
fourths  of  a  quart  of  water,  or,  more  exactly,  60  parts  of  water  by 

1  "Preventive  Medicine  and  Hygiene,"  1913,  p.  982,  where  a  full 
account  of  the  methods  of  this  class  will  be  found. 

^  The  "Convenient  Formulae"  given  in  this  Appendix  are  reprinted 
from  Rosenau's  "Preventive  Medicine  and  Hygiene,"  1913,  p.  1023  f., 
by  permission  of  D.  Appleton  and  Company.  Copyright,  1913,  by 
D.  Appleton  and  Company. 


AFM'KNDfX   A  573 

weight  with  loo  parts  of  lime.     A  flry  powfler  of  slakcfl  lime  (cal- 
cium hydroxide)  results.     Preiiare  the  milk  of  lime  shortly  before 
it  is  to  be  used  by  mixing  l   (juart  of  this  dry  calcium  hydroxide 
with  4  quarts  of  water.     Air-slaUed  lime  is  worthless.     .Slaked  lime 
may  be  [^reserved  some  time  if  inclosed  in  an  air-tight  container. 
Milk  of  lime  is  especially  useful  for  the  disinfection  of  feces;    an 
equal  quantity  should  be  added  to  the  mass  and  thoroughly  mixed. 
Since  (he  lime  settles  to  the  bottom  of  the  container,  the  milk  of 
lime  should  be  thoroughly  agitated  just  before  use.     If  necessary  to 
preserve  lime  mixtures  for  any  length  of  time  they  must  be  kept  in 
air-light  containers.     It   is   best   prepared    fresh   each   day   and    kept 
covered. 

If  quicklime  is  used  directly  without  previous  addition  of  water  it 
should  be  mixed  thoroughly  with  the  excreta  or  other  matter  to  be 
disinfected,  and  there  should  be  sufficient  liquid  present  to  insure  its 
being  fully  slaked.^ 

Chlorinated  Lime  (Hypochlorite  of  Lime,  Calcium  Hypochlorite, 
"  Chloride  of  Lime  ")  ^  is  one  of  the  most  efficient  germicides,  and  its 
cost,  even  at  retail,  is  low.  Popularly  it  is  known  as  "bleaching 
powder"  or,  incorrectly,  as  "chloride  of  lime."  Its  efficiency  is 
measured  by  the  amount  of  available  chlorine  which  it  contains;  this, 
according  to  the  U.  S.  Pharmacopoeia,  should  be  not  less  than  35 
per  cent.  It  should  be  purchased  and  kept  in  air-tight  containers, 
for  it  deteriorates  on  contact  with  the  air,  such  deterioration  being  indi- 
cated by  a  strong  odor  of  chlorine  gas  (freshly  prepared  it  has  only  a 
very  slight  odor)  and  a  pasty  condition  of  the  substance.  In  this  con- 
dition its  germicidal  power  is  much  reduced;  it  should  therefore  be 
used  only  in  a  fresh  or  well-preserved  condition. 

The  dry  substance  may  be  used  to  disinfect  excreta.  For  this  pur- 
pose, recommends  Rosenau,  enough  of  the  chlorinated  lime  must  be 
added  and  well  incorporated  with  the  mass  to  be  equivalent  to  a  4  or  5 
per  cent  solution. 

Convenient  Formula  ^ 

Chlorinated  lime 3  ounces  .  30  grams 

Water i  gallon    .     i  liter 

^  A  method  depending  upon  the  heat  evolved  in  the  slaking  of  lime 
is  described  by  Prausnitz  in  Trans.  XV  Internat.  Congress  Hyg.  and 
Demogr.,  1912,  vol.  IV,  pt.  I,  p.  30.     See  infra,  p.  584. 

2  For  a  complete  account  of  the  uses  of  this  substance  as  a  disin- 
fectant see  Hooker,  "Chloride  of  Lime  in  Sanitation,"  John  Wiley  and 
Sons,  Inc.,  1913. 

'  From  Rosenau,  see  note,  p.  572. 


574  A   MANUAL   FOR    IIKALTH    OFFICKRS 

Mix.     This  is  about  a  3  per  cent  solution.     It  is  exceedingly 

powerful  and  is  useful  for  the  disinfection  of  excreta,  privy  vaults, 

cesspools   and   many  other  purposes.     It   is  an  active  bleaching 

agent  and  destroys  fabrics  in  this  concentration. 

If  kept  for  any  length  of  time  the  solution  should  be  placed  in  a 

stone  jug  with  tightly  filling  stopper,  to  check  deterioration  by  light 

and  air. 

Since  chlorinated  lime  is  cheap  it  may  be  used  freely  in  excess  of 
theoretical  requirements,  so  as  to  insure  thorough  action. 

A  special  use  of  chlorinated  lime  is  in  the  disinfection  of  drinking 
water  (see  p.  412). 

Carbolic  Acid  (phenol  and  allied  chemical  compounds)  is  an  efficient 
germicide,  though  expensive  unless  the  crude  variety  is  used. 

Convenient  Formula  ' 
Crude  carbolic  acid  (or  phenol)      7  ounces  .  50  c.c. 

Water i  gallon    .      i  liter 

The   solution   is  facilitated   by   dissolving   in   hot   water.     This 
makes  approximately  a  5  per  cent  solution.     The  addition  of  from 
12  to  14  ounces  of  common  salt  to  each  gallon  increases  its  germi- 
cidal power,  especially  when  used  for  the  disinfection  of  excreta. 
The  crude  carbolic  acid  is  more  powerful  than  pure  phenol,  but 
can  only  be  used  for  rough  work,  such  as  floors,  feces,  sputum,  etc. 
For  the  disinfection  of  clothing  phenol  should  be  used  and  the 
solution  may  be  mixed  half  and  half  with  water,  making  approxi- 
mately a  22  per  cent  solution. 
The  Cresols  are  substances   related  to  carbolic  acid,  such  as  cresol, 
creosote,  trikresol,  etc.     They  have  a  smell  similar  to  that  of  carbolic 
acid  and  are  efficient  germicides,  having  coefficients  higher  than  pure 
carbolic   acid.     Most  of  the  commercial   disinfectants  on   public  sale 
are    mixtures   in   which    such   substances   play   the   chief   part.     The 
"liquor  cresoHs  compositus"  of  the  U.  S.  Pharmacopoeia  is  a  mixture 
of  this  class.     The  various  commercial  preparations  of  this  kind  are 
too  numerous  to  mention  here.     Many  of  them  have  high  coefficients, 
but  they  should  be  subjected  to  bacteriological  test  (see  p.  589),  before 
being  relied  upon.     Many  have  been  so  tested  by  the  Hygienic  Labo- 
ratory of  the  U.  S.  Public  Health  Ser^'ice  "^  and  by  various  state,  city 
and  private    laboratories.      A  great  deal  is  to  be  said  for  the  cresols 
as  cheap,  effective  disinfectants  having  comparatively  low  poisonous 
properties. 

1  From  Rosenau,  see  note,  p.  572. 

2  Apply  to  the  Hygienic  Laboratory  for  information.     Cf.  list  pub- 
lished in  Hyg.  Lab.  Bull.,  no.  82. 


APPENDIX   A  575 

Bichloride  of  Mercury  (Corrosive  Sublimate),  a  jjowerful  germicide, 
is  a  while  ])ovv<lcr  (^r  crystals  soluble  in  water.  Solutions  may  be 
conveniently  prepared  from  the  bichloride  tablets  sold  t;y  druggists. 
These  tai)lets  contain  a  blue  coloring  matter  to  distinguish  the  solu- 
tion as  highly  poisonous.  The  formula  below  may  also  be  used. 
While  bichloride  is  a  valuable  germicide  for  certain  purposes,  l>cing 
one  of  the  most  powerful  known  to  the  chemist,  it  has,  in  addition  to 
its  poisonous  character  (which  makes  it  especially  dangerous  when 
children  or  careless  or  ignorant  persons  have  access  to  it),  the  disad- 
vantages that  its  strength  is  absorbed  by  organic  matter  (through  pre- 
cipitation by  albuminous  substances)  and  that  it  attacks  metals.  Thus 
its  use,  while  dependable  under  proper  conditions,  has  certain  limita- 
tions. 

Convenient  Formula ' 

Bichloride  of  mercury i  dram        i  gram 

Water i  gallon       i  liter 

Mix   and    dissolve.     Label    "Poison!"     This   is   approximately 

a  I  to  looo  solution.     One  ounce  of  this  solution  contains  very 

nearly  half  a  grain  of  corrosive  sublimate.     Useful  for  disinfecting 

clothing,  the  hands,  the  surfaces  of  walls,  floors,  furniture,  etc. 

Not  serviceable  for  feces  or  material  containing  much  organic 

matter. 

A  little  bluing  may  well  be  added  as  a  warning  as  to  its  poisonous 

nature.     Keep  In  glass,  earthenware  or  wooden  vessels.     Do  not  put 

into  metal  receptacles  nor  pour  into  metal  drains. 

Formalin,  a  solution  of  formaldehyde  gas  in  water,  is  one  of  the  most 
trustworthy  and  useful  germicides  available  for  general  use.  It  is 
effective,  not  very  poisonous,  not  injurious  to  most  articles  (it  has, 
however,  an  injurious  effect  on  leather,  furs  and  skins),  and  in  addition 
acts  as  a  true  deodorant.  Formalin  solution  is  somewhat  unstable 
and  should  be  kept  cool,  dark  and  well  corked.  Disinfection  with 
formaldehyde  gas  will  be  described  presently  under  the  head  of  Gases. 

Convenient  Formula^ 

Formalin 13  ounces      100  c.c. 

Water i  gallon  i  liter 

Formalin  is  a  waterj-  solution  containing  40  per  cent  formalde- 
hyde. The  above  solution  contains  approximately  10  per  cent  of 
formalin  and  is  useful  for  the  disinfection  of  clothing  and  a  great 
variety  of   objects.     As   it   has   no  corrosive  action   it   does   not 

^  From  Rosenau,  see  note,  p.  572. 


576  A  MANUAL   FOR   HEALTH  OFFICERS 

bleach   pigments  or  rot   fabrics.     When   used   to  disinfect   feces 

twice  the  above  strength  should  be  used. 
Effects  of  Org.anic  Matter.'  —  In  the  use  of  chemical  disin- 
fectants it  must  be  borne  in  mind  that  their  action  may  be  more  or  less 
weakened  by  organic  matter,  which  may  hinder  the  disinfection  process 
either  by  chemically  absorbing  the  strength  of  the  disinfectant  —  as 
in  the  case  of  bichloride  of  mercury  —  or,  if  the  organic  matter  is  pres- 
ent in  the  form  of  particles,  by  physically  preventing  the  access  of  the 
disinfectant  solution  to  all  parts  of  the  substance  to  be  disinfected. 
The  latter  is  likely  to  be  the  case  with  sputum,  feces,  thick  pus  and  the 
like,  unless  care  is  taken  thoroughly  to  break  up  and  mix  the  mass 
with  the  disinfectant.  Further,  it  is  wise  to  use  an  excess  of  the  disin- 
fectant, and  to  employ  those  cheap  substances,  such  as  cresols,  chlo- 
ride of  lime,  etc.,  which  may  without  hesitation  be  used  liberally, 
though  of  course  such  liberality  does  not  dispense  from  all  due  care  in 
the  operation.     Bichloride  should  never  be  used  for  disinfecting  organic 

matter. 

B.   Gases 

Disinfection  by  gas,  popularly  called  "fumigation,"  is  a  measure 
commonly  employed  for  room  disinfection  after  removal,  death  or  re- 
covery of  the  patient.  The  limitations  —  even  absence  of  value  in 
most  cases  —  of  this  process  have  already  been  discussed  in  Part  II, 
Chapter  I.  The  methods  are  here  given  for  what  they  may  be  worth 
and  because  extreme  precaution  may  at  times  require  this  form  of 
disinfection,  which  is  still  in  very  general  use. 

Effective  gaseous  disinfection,  while  it  does  not  penetrate  deeply 
into  fabrics  and  the  like,  disinfects  the  surfaces  upon  which  infectious 
matter  is  lodged  or  smeared.  The  object  is  to  disinfect  such  surfaces 
and  not  the  air,  which  (except  possibly  in  some  cases  for  dust),  is 
practically  not  a  vehicle  of  infection.  If  proper  routine  disinfection 
of  discharges  and  infected  articles  is  carried  during  the  course  of  a 
communicable  disease  and  possible  infected  surfaces  washed  or  wiped 
off  with  a  liquid  disinfectant,  it  is  obvious  that  terminal  disinfection 
by  means  of  formaldehyde  or  other  gas  should  be  of  little  or  no  value 
and  may  under  such  circumstance  be  discarded  as  a  routine  measure 
(see  p.  131  fT.). 

Fumigation  with  sulphur  and  other  special  gases,  on  the  other  hand, 
is  a  valuable  measure  in  exterminating  insects. 

Fonnaldehyde.  —  The  chief,  and  almost  the  only,  gas  employed  for 
destruction  of  pathogenic  microorganisms  is  formaldehyde,  which  is 
practically   non-poisonous  to   man  and   animals  and    non-destructive. 

'  Cf.  reference  to  standardization  of  disinfectants  with  and  without 
organic  matter,  p.  590. 


AJ'F'KNDFX   A  577 

It  is  effective  to  this  purpose  if  ;i|)plie(l  with  attention  to  all  essential 
details.  A  great  deal,  however,  of  n)(jin  disinfection  as  carried  out  in 
routine  practice  at  the  present  time  is  iinfloubterlly  ineffective,  for  the 
reason  that  insuflicient  materials  arc  used,  the  apartment  is  not  jjrop- 
erly  prepared,  or  essential  conditions  as  to  moisture,  temperature,  etc., 
are  neglected. "^  Room  disinfection  requires  skill,  judgment  and  care 
on  the  part  of  the  disinfector,  and  directions  must  be  strictly  adhered  to. 

Anything  less  than  thoroughness  in  gaseous  disinfection  is  a  waste 
of  time,  labor  and  materials.  Where  it  is  deemed  advisable,  it  is 
certainly  worth  carrying  out  completely  in  accordance  with  scientific 
principles.  It  should,  therefore,  not  be  left  to  the  householfler  or  family 
physician,  but  should  be  performed  by  an  expert  offtcial  of  the  health 
department,  and  at  public  expense;  thus  only  can  uniformly  reliable 
results  be  assured. 

The  first  step  in  practical  application  is  the  preparation  of  the  apart- 
ment. Since  the  room  must  be  vacated  before  the  disinfection  process 
is  applied,  it  is  customary  for  the  patient  to  take  a  disinfectant  bath 
and  put  on  fresh  clothes,  leaving  the  old  ones  in  the  apartment. 

First,  articles  to  be  disinfected  should  be  distributed  about  or  (e.g., 
bedding)  hung  on  lines  so  as  to  allow  free  access  of  the  gas,  but  on  the 
other  hand  they  should  not  be  so  much  rearranged  from  the  original 
order  as  to  cover  up  possibly  infected  parts.  Bureau  drawers  and 
closets  should  be  opened  and  their  contents  spread  out.  Articles  of 
little  or  no  value  which  have  been  exposed  to  infection  and  may  be 
destroyed  by  fire  should  be  at  once  so  treated. 

Second,  the  room  must  be  properly  sealed.  Since  the  amount  of 
gas  which  may  escape  even  from  a  well-sealed  apartment  is  much 
greater  than  would  be  supposed,  it  is  essential  to  make  the  room  as 
nearly  air-tight  as  possible.  Chimneys,  registers  and  other  large  open- 
ings must  be  closed  or  tightly  stopped  up.  Cracks  and  crevices,  e.g., 
the  cracks  about  doors  and  windows,  the  keyholes,  etc.,  should  be 
either  well  caulked  (as  with  paper  or  cotton),  or  sealed  with  adhesive 
tape.  The  cracks  under  doors  are  likely  to  be  wide  and  should  be 
thoroughly  stopped.  When  adhesive  tape  is  used  the  dust  shoijld  first 
be  wiped  from  the  surfaces  to  which  it  is  to  be  applied.  Health  depart- 
ment adhesive  tape  about  I5  inches  wide  is  manufactured  for  the 
purpose  and  is  very  convenient,  but  care  must  be  taken  to  see  that  it  is 
really  adhesive  after  drying.  A  damp  cloth  or  sponge  for  moistening 
the  tape  and  cleaning  dusty  surfaces  is  a  convenient  part  of  the  disin- 
fector's  outfit. 

^  See  experiments  reported  in  Ann.  Rpt.  of  the  State  Inspectors  of 
Health  of  Massachusetts,  1910,  pp.  108-120,  quoted  in  Am.  Jour.  Pub. 
Health,  1912,  vol.  II,  no.  2,  p.  131. 


578  A   MANUAL   FOR   HEALTH   OFFICERS 

All  crevices  and  openings  having  been  stopped  up  except  one  door 
or  window  left  for  exit,  the  operator  starts  the  process  for  liberating 
the  gas,  leaves  the  room  and  seals  the  cracks  around  the  exit  door  or 
window  on  the  outside. 

The  secret  of  success  in  any  process  of  formaldehyde  disinfection  is 
to  liberate  a  large  volume  of  the  gas  in  a  short  time  and  with  the  right 
physical  conditions.     Hence  the  following  requirements:  — 

1.  The  amount  of  material  used  should  be  somewhat  in  excess  of 
the  estimated  requirements,  in  order  to  make  up  for  loss  by  leakage, 
through  conditions  not  being  quite  perfect,  etc. 

2.  The  gas  should  be  liberated  rapidly. 

3.  Moisture  is  necessary,  and  the  more  humidity  produced  the 
more  active  the  disinfectant  action  (hence  the  advantage  in  processes 
which  liberate  more  or  less  moisture). 

4.  The  room  should  be  warm  —  at  least  comfortable  living  tempera- 
ture (65°  P.). 

If  any  one  of  the  above  conditions  is  not  fulfilled  the  results  may  be 
vitiated. 

The  time  necessary  varies  according  to  conditions,  and  since  practi- 
cal conditions  are  usually  not  perfectly  favorable,  an  excess  of  time 
should  be  allowed.  The  least  time  allowed  should  be  six  hours.  At 
the  end  of  the  time  the  gas  may  be  dispelled  by  opening  doors  and 
windows,  so  far  as  possible  from  the  outside.  If  necessary  for  the 
operator  to  enter  a  room  where  there  is  considerable  gas  he  may  cover 
mouth  and  nose  with  a  wet  towel  and  act  quickly,  for  the  gas,  though 
not  poisonous,  is  highly  irritating  to  the  mucous  membranes  of  the 
nose,  throat  and  eyes.  The  best  time  to  disinfect  is  at  night,  for  then 
the  room  may  remain  closed  over  night  and  in  the  morning  most  of 
the  gas  will  probably  be  found  to  have  diffused  away. 

The  chief  limitation  of  formaldehyde  gas  lies  in  the  fact  that  it 
does  not  penetrate  to  any  material  extent  in  fabrics,  e.g.,  bedding  and 
the  like;  hence  if  these  are  to  be  subjected  to  more  than  surface  disin- 
fection they  should  be  soaked  in  disinfectant  solution  or  subjected  to 
some  other  more  penetrating  process. 

Controls  of  Disinfection.  —  The  final  test  of  gaseous  disinfection  is 
whether  the  microorganisms  present  are  actually  killed.  Such  a  test 
may  readily  be  carried  out  by  means  of  a  bacteriological  "control." 
If  there  is  any  doubt  as  to  the  efficiency  of  a  process  of  disinfection  it 
should  be  so  tested.  For  this  purpose  Rosenau  recommends  saturat- 
ing threads  with  an  active  culture  of  B.  prodigiosns.  These  are  attached 
to  little  strips  of  paper  which  are  then  exposed  in  various  parts  of  the 
room.  After  the  process  of  disinfection  the  threads  are  inoculated 
into  Dunham's  peptone  medium.  If  the  B.  prodigiosns  has  survived 
the  characteristic  red  color  appears  in  the  culture  medium. ^ 

'   "Preventive  Medicine  and  Hygiene,"  1913,  p.  969. 


APPENDIX   A  579 

Methods  of  Formaldehyde  Production,  —  I'ornialdeliydt:  gas  dis- 
solves in  water  and  the  solution  thus  formed,  containing  about  40 
per  cent  of  the  gas  by  weight,  is  known  as  formalin  (p.  575).  The 
gas  may  also  be  condensed  into  a  powder  known  as  paraform.  F"or 
purposes  of  disinfection  formaldehyde  gas  may  be  produced  by  boiling 
formalin  either  under  or  without  pressure  or  under  partial  vacuum, 
by  heating  paraform  powder,  by  mixing  potassium  permanganate  and 
formalin  (or  paraform  with  water),  or  by  mixing  formalin,  lime  and 
aluminum  sulphate.  Formaldehyde  disinfection  may  also  be  per- 
formed by  sprinkling  articles  hung  up  in  the  room  with  formalin  solu- 
tion, which  evaporates,  thus  permeating  the  room  with  the  gas. 

The  following  are  among  the  more  practicable  methods  of  producing 
the  gas: 

The  Permanganate-paraform  Method.  —  The  following  method 
has  been  tested  out  by  the  Department  of  Health  of  New  York  City 
and  found  both  effective  and  convenient.^ 

Formula: 

Potassium  permanganate 75  grams      2.5  ounces 

Paraformaldehyde    (solid   formal- 
dehyde in  powder  form) 30  grams      I      ounce 

Water 90  grams      3      ounces 

The  two  chemicals  are  put  up  separately  in  small  round  paper 
boxes.  A  number  of  these  may  be  prepared  at  one  time  and,  if  dipped 
in  melted  paraffin  so  as  to  make  them  air-tight,  may  be  kept  on  hand 
in  a  cool  place  for  some  weeks.  After  a  pair  of  samples  have  been 
carefully  weighed  out  small  measures  may  be  made  and  the  rest  of  the 
amounts  may  be  rapidly  measured  out  by  volume.  For  mixing  and 
for  setting  off  the  mixture  small  deep  tin  trays  (§  quart  size)  may  be 
used.  Where  there  are  many  disinfections  to  be  performed  it  is  con- 
venient to  use  water-tight  paper  trays  5  or  6  inches  square  and  about 
3  inches  in  depth  which  may  be  abandoned  after  use.  Both  boxes  and 
trays  may  be  obtained  inexpensively  if  purchased  in  lots  of  500  or  1000 
or  more  from  manufacturers  of  paper  goods.  The  disinfector  should 
be  provided  with  a  small  measure  for  water.  A  unit  for  each  1000 
cubic  feet  would  consist  of  one  box  of  each  chemical  and  one  measure 
(3  oz.)  of  water.  The  two  chemicals  are  thoroughly  mixed  dry  in  the 
tray,  or  trays  (several  should  be  used  if  the  apartment  contains  more 
than  2000  cubic  feet  of  air  space).  For  safety's  sake  each  paper  tray, 
where  these  are  used,  should  be  placed  In  a  dish  or  tin  pan  containing 

^  Schroeder,  "Municipal  Disinfection  in  New  York  City  as  Re- 
cently Reorganized,"  Am.  Jour.  Pub.  Health,  1912,  vol.  ii,  no.  8,  p.  591. 


580  A  MANUAL   FOR   HEALTH   OFFICERS 

warm  water  to  the  depth  of  lialf  an  inch  or  so.  Warm  water  to  the 
quantity  required  is  then  added  to  the  contents  of  each  tray  and  rap- 
itlly  and  thoroughly  mixed  in  with  a  small  glass  or  wooden  rod.  The 
evolution  of  the  gas  does  not  begin  at  once,  so  the  operator  has  time  to 
lea\-e  the  room  and  seal  the  door  without  being  annoyed  by  the  fumes. 
The  gas  is  practically  all  gi\'en  off  in  five  to  ten  minutes.  The  mois- 
ture necessary  for  efficiency  is  evolved  at  the  same  time.  The  method 
has  the  advantages  of  efficiency,  lightness  of  materials,  convenience  of 
operation  and  low  cost  (about  9  cents  per  unit  of  1000  cubic  feet). 
Materials,  as  with  other  methods,  should,  in  order  to  insure  thorough 
action,  be  used  somewhat  in  e.\cess  of  estimated  requirements. 

The  Perm.\nganate-formalin  Method.'  —  Use  500  c.c.  [17 
fluid  oz.]  of  formalin  and  250  grams  [8.8  oz.]  of  potassium  perman- 
ganate for  each  thousand  cubic  feet  of  air  space.  The  jierman- 
ganate  is  first  placed  in  a  bucket  or  basin  and  the  formalin  poured 
upon  it.  An  active  effervescence  takes  place  and  considerable 
heat  is  evolved;  therefore  a  pail  of  sufficient  capacity,  and  espe- 
cially of  sufficient  height,  should  be  used  to  prevent  splashing  or 
boiling  over.  In  Board  of  Health  work  it  is  advisable  to  have 
galvanized  iron  pails  made  for  this  purpose  with  a  flaring  top. 
The  floor  should  be  protected  against  the  heat  by  placing  the  bucket 
upon  a  brick,  board,  or  other  suitable  device. 

When  the  permanganate  of  potassium  and  formalin  arc  brought 
in  contact  very  active  oxidation  takes  place,  with  the  formation 
of  formic  acid  and  heat.  It  is  the  heat  that  liberates  the  formalde- 
hyde gas.  Chemically,  therefore,  the  method  is  a  wasteful  one, 
but  practically  a  very  serviceable  one.  It  was  first  described  by 
Johnson  of  Sioux  City,  Iowa,  in  1904.  In  the  same  year  Evans 
and  Russell  of  Augusta,  Maine,  used  the  method.- 

The  Formalin-lime  and  Aluminium  Sulphate  Method.^  — 
This  method  was  first  described  by  Walker  of  the  Department  of 
Health,  Brooklyn,  N.  Y.  It  is  somewhat  slower  than  the  potas- 
sium permanganate  method,  but  otherwise  appears  to  be  just  as 
efficient. 

^  This  method  and  the  following  are  reprinted  from  Rosenau,  "Pre- 
ventive Medicine  and  Hygiene,"  1913,  pp.  996-97,  by  permission  of 
D.  Appleton  and  Company.  Copyright,  1913,  by  D.  Appleton  and 
Company. 

'•  A  convenient  permanganate-formalin  outfit  consisting  of  a  unit 
for  a  single  room  is  described  by  Freeman,  Am.  Jour.  Pub.  Hyg.,  1909, 
voL  XXV,  p.  361. 

^  Reprinted,  by  permission,  from  Rosenau.     See  note  supra. 


APPENDIX  A  581 

The  proportions  for  each  1000  euljic  feet  are  as  follows: 

Sol.  A.  — Alumiiiiiiin  sulphate 150  grams     [  5.3  oz.) 

Dissolved  in  hot  water. .. .        300  c.c.  [10.2  fluid  oz.) 

Sol.  B.  —  Formalin  (40%  CllOII) .  .        600  c.c.  [20.4  fluid  o/.] 

Lime.  —  Unslaked  lime 2000  grams     [70  oz.] 

Mix  solutions  A  and  B  and  i)our  ui)on  the  lime. 

In  practical  work  20  to  25  pounds  of  the  commercial  aluminium 
sulphate  is  dissolved  in  5  gallons  of  hot  water.     This  is  sufficient 
to  mix  with   15  gallons  of  a  40  per  cent  formaldehyde  solution 
and   then   used   in   the   proportions  as   stated   above.     The   lime 
should  be  freshly  burned,  broken  into  small  particles,  and  should 
slake  rapidly  in  cold  water.     The  lime  is  placed  in  a  large  bucket. 
The  formalin  and  aluminium  sulphate  solutions  should  be  mixed 
and  poured  over  the  lime.     In  a  few  minutes  the  lime  begins  to 
slake  and  the  heat  evolved  drives  off  the  formaldehyde  gas. 
Commercial  "candles"  or  "lamps"  for  the  production  of  formalde- 
hyde from  paraform  compounds  are  on  the  market;    some  of  these  are 
convenient  and  to  a  greater  or  less  degree  effective.     They  do  not, 
however,  as  a  rule  supply  the  extra  moisture  frequently  needed.     Such 
articles  should  be  bacteriologically  tested  as  above  described  before 
purchasing,  and  should  be  retested  from  time  to  time  in  order  to  detect 
possible  deterioration  in  manufacture  or  storage.     In  selecting  a  method 
of  disinfection  expense  must  be  considered  and  the  unit  costs   (per 
thousand  cubic  feet)  of  the  various  methods  proposed  should  be  com- 
pared.    Prices  on  formalin,  permanganate,  etc.,  in  bulk  will  be  quoted 
by  wholesale  chemical  dealers.     The  strength  of  formalin  is  likely  to 
vary  below  the  theoretical  40  per  cent  solution  (average,  according  to 
Rosenau,  36  per  cent),  so  that  unless  its  strength  is  known  an  excess 
should  be  figured.     The  amount  of  air  space  for  which  each  candle  is 
effective,  in  the  case  of  the  commercial  "candles,"  should  be  deter- 
mined by  bacteriological  experiment  to  check  up  the  manufacturer's 
statement. 

DISINFECTANTS  FOR  SPECIFIC  USES 

The  choice  of  a  disinfectant  in  any  given  case  will  depend  upon: 
(i)  its  efficiency  and  its  applicability  to  the  purpose  in  view;  (2)  ease 
of  application;    (3)  cost  and  (4)  disadvantages. 

Health  authorities  should  definitely  prescribe  practical  and  effective 
methods  of  disinfection,  and  should  also  supply  any  needed  chemicals 
in  a  convenient  form  at  public  expense.  In  many  instances  this  im- 
portant phase  of  prevention  is  slighted  and  the  measures  taken  are 
perfunctory  and  ineffective.  The  primary-  responsibility  for  seeing 
that  disinfection  is  properly  performed  throughout  the  course  of  each 


58 2  A   MANUAL   FOR   HE.\LTH   OFFICERS 

case  of  communicable  disease  rests  with  the  health  authorities,  whose 
rules  in  connection  with  such  cases  should  be  explicit  and  should 
be  explained  and  their  observance  supervised  in  detail  by  the  sanitary 

inspector. 

The  following  arc  the  disinfectant  agents  chielly  to  be  recommended 
for  certain  specific  uses.  For  formulae  and  application  see  preceding 
pages. 

Two  rules  should  be  borne  in  mind  throughout: 

Disinfection  may  stipplemcnt  care  and  cleanliness  in  the  sick-room  and 
house,  hut  cannot  take  its  place. 

Prefer  heal  {burning  and  boiling),  the  simple  and  universal  disinfectant, 
so  far  as  possible,  to  other  methods. 

Sputum,  Discharges  from  Mouth  and  Nose,  etc.,  should  so  far  as 
possible  be  caught  on  pieces  of  cloth,  gauze,  or  absorbent  cotton,  and 
burned  up.  Destructible  sputum  cups  are  useful.  Chemical  disinfec- 
tants, to  be  allowed  to  stand  in  contact  half  an  hour  or  more:  carbolic 
acid,  5  per  cent;  formalin,  lo  per  cent  or  stronger;  chlorinated  lime, 
3  per  cent;  but  these  frequently  do  not  penetrate  into  particles  of 
sputum,  etc.  Ordinarj-  cups  or  cuspidors  should  contain  water,  which 
will  hold  the  sputum  until  it  can  be  disinfected.  Paper  cuspidors 
which  can  be  frequently  burnt  up  and  replaced  are  to  be  recommended. 
Excreta.  —  Proper  disinfection  of  feces  and  urine  requires  care  in 
the  application  of  any  of  the  following  methods: ' 

From  patients  the  discharges  should  be  received  in  a  glass  or 
impervious  vessel  containing  some  of  the  germicidal  substance, 
more  of  which  is  added  afterwards,  and  the  mass  thoroughly  mixed. 
The  mixture  should  stand  at  least  one  hour  before  the  contents 
are  disposed  of,  and  the  vessel  given  a  thorough  cleansing  and  dis- 
infection before  it  is  again  used.  At  least  an  equal  quantity  of 
the  germicidal  solution  should  be  used  to  the  mass  disinfected  and 
enough  should  always  be  added  to  entirely  submerge  the  mass. 
Excreta  must  always  be  protected  from  fiies  and  other  insects, 
even  while  undergoing  disinfection. 

Milk  of  Lime.  —  Use  freshly  prepared  milk  of  lime  containing 
I  part  by  weight  of  the  freshly  slaked  lime  to  4  parts  of  water. 
Add  at  least  an  equal  quantity  to  the  amount  of  material  to  be 
disinfected  and  allow  the  mixture  to  stand  no  less  than  two  hours 
before  final  disposiil.     The  perfunctory  sprinkling  of  fecal  matter 
with  lime  or  milk  of  lime,  as  is  often  done,  is  not  efTective.     Lime 
should  not  be  thrown  into  the  hoppers  of  water-closets  for  the 
1  Reprinted  from  Rosenau,  "Preventive  Medicine  and  Hygiene," 
1913,  p.   1030,  by  permission  of  D.  Apijleton  and  Company.     Copy- 
right, 1913,  by  D.  Appleton  and  Company. 


APPENDIX  A  583 

disinfection  of  dejecta,  for  otherwise  a  thick  mass  will  accumulate 
and  obstruct  the  pipes.  In  disinfecting  excreta  with  lime  the 
reaction  of  the  resulting  mixture  must  he  alkaline  else  the  object 
will  not  be  attained. 

Lime  or  milk  of  lime  is  very  useful  for  (he  disinfection  of  privies, 
or  trenches  in  camp,  or  in  country  practice.  For  its  use  under  these 
circumstances  the  amount  required  may  be  arrived  at  as  follows: 
The  amount  of  fecal  matter  per  person  is  reckoned  at  400  grams  a 
day.  If  the  urine  is  also  to  be  disinfected  this  may  be  counted  as 
1500  to  2000  c.c.  per  person  daily.  For  the  disinfection  of  the 
solid  excrement  alone  5  grams  of  lime,  or  40  c.c.  of  the  milk  of  lime 
(i  to  8),  must  be  reckoned  for  each  person  per  day.  If  the  urine 
is  included  it  will  take  four  to  five  times  as  much.  The  mixture 
must  have  an  alkaline  reaction.  Attention  is  again  called  to  the 
fact  that  air-slaked  lime  is  inert. 

Chlorinated  Lime.  —  This  is  one  of  the  most  useful  and  potent 
germicidal  substances  for  the  disinfection  of  feces.  Use  at  least 
a  3  per  cent  solution  and  an  amount  equal  to  the  mass  to  be  dis- 
infected. Thoroughly  mix  and  allow  to  stand  at  least  2  hours. 
Chlorinated  lime  combined  with  air  is  rendered  inert  by  organic 
matter;   therefore  an  excess  should  always  be  used. 

Formalin.  —  A  10  per  cent  solution  of  formalin  may  be  de- 
pended upon  to  disinfect  feces  if  thoroughly  incorporated  with 
the  mass  and  allowed  to  stand  at  least  one  hour.  As  a  deodorant 
it  acts  almost  instantly. 

Carbolic  Acid.  —  A  5  per  cent  solution  o£  crude  carbolic  acid 
added  to  an  equal  bulk  of  excreta  may  be  depended  upon  to  disin- 
fect in  one  to  two  hours,  provided  the  germicide  is  thoroughly 
incorporated  throughout  the  mass. 

The  cresols  and  the  alkaline  coal-tar  creosotes  are  valuable 
agents  for  the  disinfection  of  fecal  matter  in  small  amounts  on 
account  of  their  energetic  action  and  because  their  efficienc}"  is 
not  greatly  impaired  by  the  presence  of  albuminous  matter.  As 
a  rule  substances  in  emulsion  lack  the  power  of  penetration,  and  If 
used  must  be  very  thoroughly  mixed  and  incorporated  with  the  mass. 

Dry  earth  promotes  the  disinfection  of  excreta,  thus  delajing 
putrefactive  changes  while  absorbing  the  odors.     It  has  no  inher- 
ent  germicidal   qualities.      Corrosive   sublimate   is   unfit   for   the 
disinfection  of  feces  and  sputum. 
(For  formulae  and  details  for  the  use  of  the  above-mentioned  disin- 
fectants see  pp.  572-5.) 

Doty  calls  attention   to  the   practical   difficulties   of  the   ordinary- 
methods   of   disinfecting   excreta   by   chemical   agents,    mentions   the 


584  A  MANUAL   FOR  HEALTH  OFFICERS 

necessity  for  disinfecting  the  vessel  as  well  as  the  contents,  and  recom- 
mends the  use  of  lieal,  describing  a  water-bath  which  is  applicable 
where  the  necessary  apparatus  can  be  improvised  or  installed.  The 
method  has  thus  far,  apparently,  been  utilized  only  in  hospitals. 

I  belie\e  there  is  but  one  way  to  deal  with  infected  discharges 
of  this  kind,  if  it  can  be  made  use  of,  and  that  is  by  heat  —  either 
boiling  water  or  steam.  Some  simple  means  of  performing  this 
may  be  improvised  wherever  a  metal  receptacle  of  sufficient 
capacity  and  a  fire  can  be  secured,  or  a  simple  and  inexpensive 
apparatus  may  be  made  as  follows:  A  sheet-copper  receptacle 
sufficiently  large  to  hold  a  full-sized  bedpan  may  be  easily  con- 
structed, having  metal  supports  to  raise  it  above  the  ground  high 
enough  to  allow  room  for  a  lamp  or  gas  apparatus  to  secure  the 
necessary  heat.  The  cover  should,  if  possible,  be  made  sufficiently 
heavy  to  offset  a  slight  pressure  of  steam.  This,  however,  is  still 
further  provided  for  by  a  spout  which  is  attached  to  the  portion 
of  the  top  not  involved  in  the  cover  and  for  the  same  purpose  that 
a  spout  is  used  on  a  teakettle  —  to  allow  the  escape  of  steam. 
The  upper  end  of  this  should  be  connected  with  a  flexible  tube, 
which  may  be  carried  out  of  the  window  in  order  that  the  steam 
does  not  escape  into  the  apartment  itself.  When  not  used  the 
temperature  of  the  water  may  be  kept  short  of  the  boiling  point. 
The  addition  of  a  small  amount  of  potassium  permanganate  will 
usually  prevent  any  unpleasant  odor.  The  value  of  this  method 
lies  in  the  fact  that  when  the  bedpan  is  brought  from  the  patient 
and  placed  in  the  bath  and  exposed  to  boiling  water  for  20  min- 
utes we  may  be  certain  that  both  the  pan  and  the  discharge  are 
disinfected  and  it  makes  little  difference  what  is  done  with  them 
afterwards.  This  apparatus  is  only  a  suggestion  of  the  principle 
which  may  be  carried  out  on  a  larger  scale.  In  the  hospitals 
which  have  been  under  my  direction  large  apparatus  were  con- 
structed along  these  lines  capable  of  holding  eight  bedpans  at  one 
time.  Steam  may  be  used  instead  of  boiling  water.  This  method 
of  disinfection  is  valuable  in  any  form  of  infectious  disease  for  the 
treatment  of  discharges  or  textile  fabrics  or  other  articles  which 
may  have  been  directly  contaminated.' 
Slaking  of  Quicklime.  —  What  is  apparently  the  most  effective 
method  of  all  for  the  disinfection  of  excreta  consists  in  making  use 
of  the  heat  evolved  in  the  slaking  of  quicklime."^     It  consists  in  add- 

1  Doty,  Trans.  XV  Internal.  Congress  Hyg.  and  Demogr.,  1912,  vol. 
IV,  pt.  I,  p.  17. 

2  Prausnitz,  Trans.  XV  Internal.  Congress  Hyg.  and  Demogr.,  1912, 
vol.  IV,  p.  30;  H.  Linenthal  and  H.  N.  Jones,  Boston  Med.  and  Surg- 
Jour.,  Jan.  8,  1914  (reprinted  in  Mo.  Bull.  Mass.  State  Bd.  Health, 
Jan.,  1914. 


APPENDIX  A  585 

ing  enough  hot  water  to  cover  the  stool  in  the  receptacle  and  then 
adding  an  amount  equal  to  at  least  one-fourth  of  the  entire  bulk  of 
liquid  present  —  or  ajjout  a  cujiful  —  of  quicklime,  covering  the 
receptacle  and  allowing  it  to  stand  for  two  hours.  'l"he  slaking  of 
the  lime  generates  enough  heat  to  destroy  intestinal  organisms. 
The  water  added  should  have  a  temperature  of  at  least  50^-60°  C. 
(i20°-i40°  F.);  cold  water  cannot  be  depended  upon.  A  porcelain 
vessel  retains  the  heat  better  than  a  metal  one.  The  lime  should 
be  broken  up  into  small  fragments  and  distributed  evenly  over  the 
stool.  The  method  is  simple  and  is  applicable  in  the  household. 
If  necessary,  water  should  be  heated  in  the  sick-room,  in  order  to 
avoid  any  communication  with  the  kitchen  for  that  purpose.  Use 
fresh  unslaked  lime  which  has  been  protected  from  the  air;  old,  air- 
slaked  lime  is  inert. 

The  Hands.  —  Disinfection  of  the  hands  of  persons  nursing  cases 
of  communicable  disease  is  of  prime  importance.  Chronic  carriers  of 
disease  should  also  take  precautions  to  keep  their  hands  free  from 
infection,  which  means  that  the  hands  must  be  disinfected  after  every 
exposure  to  contamination. 

To  free  the  hands  from  infection  does  not  require  elaborate  measures. 
In  the  first  place,  thorough  washing  with  soap  and  water,  followed  by 
rinsing  in  running  water  and  thorough  wiping,  results,  as  experiment 
has  shown,  in  freeing  the  hands  from  microorganisms.  The  operation 
as  performed  by  careful  persons  under  ordinary  circumstances  would 
remove  at  least  the  great  majority  of  germs.  This  is  a  fact  of  impor- 
tance to  all  persons  who  desire  to  protect  themselves  from  the  contact 
infection  which,  as  we  have  pointed  out  in  the  discussion  in  previous 
pages,  is  readily  conveyed,  from  known  or  unknown  sources,  by  con- 
taminated fingers.  Dirty  hands,  even  though  the  dirt  is  unseen,  spell 
danger  at  all  times;  clean  hands,  relative  safety.  But,  since  most 
persons  cannot  be  depended  upon  to  be  sufficiently  careful,  it  is  well, 
where  there  is  question  of  protection  from  known  infection,  to  practice 
chemical  disinfection  as  a  safeguard. 

/n  connection  with  cases  of  communicable  disease,  the  nurse  should  first 
carefully  wash  her  hands,  then  dip  them  for  not  less  than  one  full  minute 
by  the  clock  in  a  solution  of  bichloride,  carbolic  acid  (2I  per  cent)  or  one 
of  the  cresols,  alcohol,  eau-de-Cologne  or  other  suitable  disinfectant; 
the  disinfectant  should  then  be  rinsed  off  with  clean  water  and  the 
hands  should  be  wiped  dry  with  a  towel  used  for  no  other  purpose. 
The  process  should  be  repeated  after  each  handling  of  patient,  in- 
fectious matter  or  infected  articles. 

Care  should  be  taken  that  the  hands  do  not  become  unconsciously 
recontaminated  by  handling  infected  vessels  or  articles,  and  the  waste 


586  A   MANUAL   FOR   HEALTH   OFFICERS 

water  resulting  from  the  above  process  should  be  disposed  of  so  as 
to  occasion  no  danger  of  infection,  disinfectant  being  added  to  it  if 
necessary. 

Chronic  Carriers  of  typhoid  or  other  disease  should  be  instructed 
to  take  similar  precautions  after  every  possible  contamination  of  the 
fingers;  thorough  washing  and  wiping  of  the  hands  is  the  least  that 
should  be  demanded,  preferably  followed  with  the  use  of  a  disinfectant. 

Dishes  and  Other  Eating  Utensils  should  be  placed  in  a  metal 
^■essel  (e.g.,  a  dish-jjan)  and  entirely  covered  with  water.  This  vessel 
should  be  kept  outside  of  the  sick-room  door  and  twice  a  day  it  should 
be  remo\'ed  to  the  kitchen  stove  and  its  contents  well  boiled  in  the  same 
vessel  for  twenty  minutes.     The  use  of  chemical  agents  is  not  necessary. 

Body  and  Bed  Linen  should  be  similarly  treated  in  a  separate  vessel 
such  as  an  ordinary  washboiler.  During  the  boiling  the  materials 
should  be  agitated  so  as  to  insure  penetration  of  the  boiling  water  to 
all  parts.     With  such  a  process  no  chemicals  are  necessary. 

Bedding,  such  as  blankets,  mattresses,  etc.,  which  cannot  be  boiled, 
may  be  thoroughly  sprayed  on  all  parts  with  formalin  and  shut  up  in 
a  warm  and  tight  closet,  box,  or  drawer  for  at  least  12  hours  and  then 
should  be  exposed  to  sun  and  air.  A  gaseous  formaldehyde  disinfection 
will  disinfect  the  surfaces  of  such  things  if  they  are  exposed  so  that  the 
surfaces  may  be  reached  by  the  gas.  Some  health  departments  in  the 
larger  cities  remove  bedding,  disinfect  it  by  steam,  and  then  return  it. 

Miscellaneous  Articles,  if  of  little  or  no  value,  may  be  burned.  Or 
they  may  be  boiled  or  immersed  in  a  disinfectant  solution.  Or  each 
article  may  be  sprayed  with  formalin  by  means  of  a  hand  atomizer 
and  placed  in  a  wooden  or  pasteboard  box  having  a  tight-fitting  cover, 
which  should  be  sealed  and  kept  in  a  warm  room  for  twelve  hours. 
Articles  which  would  be  injured  by  much  moisture  may  be  placed  in  a 
tight  box  or  compartment  and  subjected  to  formaldehyde  gas  with  a 
moderate  amount  of  moisture.  Magazines  and  books  which  have 
been  used  in  the  sick-room  may,  if  of  little  value,  be  burned,  or  may  be 
disinfected  as  described  below.  In  boiling  bright  metal  objects  the 
addition  of  a  small  amount  of  alkali,  e.g.,  cooking  or  washing  soda, 
will  prevent  corrosion. 

Books  may  be  disinfected  externally  by  formaldehyde  gas  and 
internally  by  placing  two  or  three  drops  of  formalin  solution  on  every 
second  page,  with  care  to  distribute  the  drops  well.  The  book  is  then 
placed  in  a  tight  box  or  drawer  in  which  more  formalin  has  been  sprin- 
kled and  left  in  a  warm  place  for  not  less  than  24  hours.  The  follow- 
ing method,  adaptable  to  larger  numbers  of  books,  is  given  by  Dr. 
Robert  J.  Wilson,  Superintendent  of  Hospitals  of  the  Department  of 
Health  of  New  York. 


MM'KNDIX   A  587 

Books  can  he  successfully  disinfected  Ijy  forniuldc^liyde  fumiga- 
tion. In  order  lo  insure  thorou^di  fumigalion  the  books  must  he 
so  arranged  as  to  insure  penetration  of  ihe  gas  jjctween  all  the 
pages.  This  is  hcst  accomplished  hy  o|)cning  the  hook  until  the 
covers  come  together  at  the  hack,  holding  them  in  this  jKjsition  hy 
a  rubber  band  or  clothespin.  This  will  cau.se  the  leaves  to  separate 
and  allow  the  gas  to  pass  between  them.  The  hooks  should  then 
be  placed  on  jjcrforated  shelves,  preferably  made  of  wire  netting, 
standing  on  end.  Formaldehyde  gas,  [derived  from]  40  per  cent 
[formalin]  solution,  from  any  kind  of  an  approved  generator,  in  the 
proportion  of  1  ounce  of  solution  for  every  100  cubic  feet  of 
space,  should  be  supplied  in  an  air-tight  box  that  contains  the 
books.  The  exposure  to  the  gas  should  not  be  less  than  four  hours. 
Test  organisms  of  common  pathogenic  organisms  exposed  under 
these  conditions  have  been  destroyed  by  the  action  of  the  gas.' 
The  internal  disinfection  of  books  is  usually  of  little  practical 
value. 

Surfaces,  such  as  woodwork,  furniture,  and  the  like,  unless  directly 
exposed  to  infection  by  smearing,  handling,  coughing,  etc.,  need  no 
general  treatment.  For  door-knobs,  bed-frames,  and  other  parts 
which  have  been  exposed,  the  cresol  compounds  are  to  be  recommended; 
also  bichloride  solution  and  other  liquid  disinfectants.  Washing  or 
scrubbing  with  soap  and  water  with  the  addition  of  a  cresol  is  useful. 
With  such  exceptions  treatment  of  woodwork,  etc.,  is  unnecessary  if 
cleanliness  has  been  observed  during  isolation. 

Terminal  or  Room  Disinfection.  —  If  the  above-mentioned  meas- 
ures have  been  carried  out,  general  room  disinfection  should  be  unnec- 
essary as  a  terminal  routine  measure  (see  discussion  in  Part  II,  Chapter 
I).  If  proper  care  has  been  exercised  during  the  isolation  there  will 
only  remain  a  few  articles  and  surfaces  in  the  sick-room  which  can 
possibly  require  disinfection,  and  these  can  be  dealt  with  as  already 
described.  At  the  present  time  terminal  disinfection  with  formalde- 
hyde gas  can  onlj^  be  regarded  either  as  an  endeavor  to  atone  for  lack 
of  proper  measures  during  the  course  of  the  disease  or  as  an  extreme 
precaution  when  such  measures  have  been  taken.  (Methods  have  been 
given  a  few  pages  back.) 

1  Jour.  Outdoor  Life,  1914,  vol.  xi,  no.  4,  p.  118.  Other  methods  of 
book  disinfection,  especially  for  larger  numbers  of  books,  are  given  in 
Rosenau's  "Preventive  Medicine  and  Hygiene,"  1913,  p.  1033.  Moist 
hot  air  in  a  specially  constructed  chamber  has  been  recommended  by 
Nice,  Jour.  Am.  Pub.  Health  Assn.,  1911,  vol.  i,  no.  11,  p.  775,  and 
Jour.  Am.  Med.  Assn.,  1912,  vol.  Iviii,  no.  16,  p.  1201. 


588  A  MANUAL   rOR   HIOALTH  OFFICERS 

Stables  are  difficult  to  disinfect  thoroughly,  but  disinfection  may  be 
necessar>'  on  account  of  glanders,  tuberculosis  and  other  animal  dis- 
eases transmissible  to  man.  The  disinfection  should  be  accompanied 
by  a  thorough  cleaning  and  a  cleansing  of  all  surfaces.  Rosenau  rec- 
ommends: first,  sulphur  fumigation  (see  below)  to  destroy  surface 
infection  and  vermin,  followed  by  burning  or  disinfection  of  such  as 
harness,  blankets,  combs,  etc.,  by  appropriate  methods;  then  a  liberal 
application  of  an  antiseptic  solution  (e.g.,  a  cresol  compound);  then 
cleaning  woodwork  with  hot  lye  or  strong  alkaline  soap  solution  fol- 
lowed by  another  application  of  disinfectant.  After  several  days 
exposure  to  air  and  sunshine  the  interior  should  receive  a  fresh  coat  of 
whitewash,  applied  quickly,  and  prepared  from  freshly  burned  lime. 
Watering  troughs  and  the  water  contained  in  them  may  require  dis- 
infection, the  disinfectant  being  afterwards  thoroughly  washed  out. 
Ground  may  be  disinfected  with  fresh  (juicklime.  Carcasses  and  ex- 
creta may  be  buried  in  quicklime.^ 

SULPHUR   FUMIGATION 

Sulphur  fumigation  is  highly  efficient  for  the  destruction  of  insects 
and  vermin."  Although  it  is  not  a  very  efficient  germicide  it  has  also 
a  certain  value  in  destroying  surface  infection.  Sulphur  is  cheap  and 
may  be  obtained  even  in  country  stores,  and  the  application  is  simple. 

As  a  germicide  sulphur  dioxide  (the  gas  formed  by  combustion  of 
sulphur)  requires  moisture.  It  does  not  penetrate,  however,  and  is 
therefore  only  useful  for  surface  disinfection.     It  does  not  kill  spores. 

As  an  insecticide  it  does  not  require  moisture,  and  penetrates  very 
effectively.  It  quickly  kills  all  forms  of  insect  and  animal  life,  e.g., 
mosquitoes,  flies,  fleas,  rats,  etc.     (On  mosquito  destruction  cf.  p.  592.) 

Its  disadvantages  are  that  it  bleaches  colors,  corrodes  metals  and 
tends  to  disintegrate  fabrics,  and  the  more  moisture  there  is  present 
the  more  pronounced  are  these  effects.  Metal  surfaces  may,  however, 
be  protected  by  a  thin  coating  of  heavy  oil  or  grease  (e.g.,  vaseline); 
while  if  exposed  fabrics  are  at  once  washed  most  of  the  damage  to  them 
can  be  avoided. 

^  For  more  detailed  account  of  methods  above  outlined,  see  Rose- 
nau, "Preventive  Medicine  and  Hygiene,"  1913,  p.  1027. 

2  Hydrocyanic  acid  gas  (prussic  acid)  is  highly  efficacious  against 
insects  and  vermin,  but  as  it  is  extremely  poisonous  to  human  beings 
it  must  be  used  with  special  precautions  and  great  care;  hence,  while 
it  may  only  be  used  in  special  classes  of  buildings,  it  has  a  very  limited 
place  as  an  insecticide  in  the  disinfection  of  dwelling  houses.  See 
Dept.  of  Rosenau,  "  Preventive  Medicine  and  Hygiene,"  1913,  p.  194. 
The  U.  S.  Dept.  of  Agriculture  publishes  instructions  for  its  use. 


AF'J'KNDIX   A  589 

'I'he  pot  mcllwd,  described  l)cl(jw,  is  rccoinnifiidcd.  Similar  condi- 
tions to  those  re(|uired  for  fornialdeliyde  disinfection  should  he  obtained 
if  germicidal  miction  is  desired,  viz.,  a  well-sealed  room,  sufficient  mois- 
ture and  at  least  comforl;ablc  room  temi)eraturc.  To  insure  insccticidal 
action  the  sealing  of  the  compartment  is  also  important  (see  page  592J. 
The  gas  is  evolved  slowly  and  if  there  are  many  cracks  and  crevices  may 
escape  nearly  as  rapidly  as  evolved.  At  low  temperatures  a  good  deal 
of  the  gas  may  be  condensed  by  the  moisture  present. 

The  pot  method  is  at  once  the  easiest,  cheapest  and  probably 
most  efficient  method  of  using  sulphur  dioxide.  The  only  mate- 
rials required  arc  iron  pots  and  some  sulphur.  The  best  way  to 
apply  the  method  is  by  placing  the  suljjhur  in  large,  flat,  iron  pots 
known  as  Dutch  ovens.  Not  more  than  30  jjounds  of  sulphur 
should  be  placed  in  each  pot.  The  sulphur  is  preferably  used  in 
the  form  of  flowers  of  sulphur.  If  it  is  in  sticks  or  rolls  it  should 
be  crushed  into  a  powder,  which  may  conveniently  be  done  by 
placing  the  sulphur  in  a  stout  box  and  pounding  the  lumps  with  a 
heavy  timber.  The  pot  holding  the  sulphur  should  be  placed  in 
a  tub  of  water  [being  raised  on  supports  off  the  bottom  of  the 
latter].  The  water  not  only  diminishes  the  danger  from  fire  and 
protects  the  floor,  but  by  its  evaporation  furnishes  the  moisture 
necessary  to  hydrate  the  sulphur  dioxide,  upon  which  the  disin- 
fecting power  of  the  gas  depends.  Thus  the  moisture  is  furnished 
automatically  and  does  away  with  the  necessity  for  its  introduc- 
tion by  means  of  steam  or  a  spray.  Although  the  specific  gravity 
of  sulphur  dioxide  is  greater  than  that  of  air,  when  hot  it  rises, 
aided  by  the  upward  current  produced  by  the  burning  sulphur. 
Hence  the  pots  should  not  be  on  the  floor,  or  at  the  bottom  of  the 
hold  in  the  case  of  vessels,  lest  the  cold  gas  settle  and  the  flame, 
being  deprived  of  oxygen,  be  extinguished  before  all  the  sulphur 
is  burned.  The  pots  may  therefore  be  placed  upon  a  table  or  box  or, 
in  the  holds  of  ships,  upon  piles  of  ballast  or  on  the  "  'tween  decks." 
The  sulphur  may  be  lighted  by  means  of  hot  coals  or  a  wood 
fire,  but  the  most  reliable  way  to  get  it  well  lighted  is  by  alcohol, 
turpentine,  or  kerosene  on  a  pledget  of  waste.  Make  a  little  crater 
of  the  sulphur,  soak  liberally  with  alcohol,  and  ignite.  The  sul- 
phur then  burns  in  the  center,  and  as  it  melts  runs  down  from 
the  sides  and  forms  a  little  lake  at  the  bottom  of  the  crater.  If  the 
sulphur  is  heaped  up  in  a  mound  in  the  pot  the  flame  is  liable  to 
go  out. 

Upon  the  principle  of  not  putting  all  our  eggs  in  one  basket,  it 
is  best  to  have  a  number  of  pots  when  a  large  compartment  is  to 
be  fumigated.     A  pot  should  contain  not  more  than  30  pounds  of 


590  A  MANUAL   FOR   HEALTH  OFFICERS 

.    sulphur,  and  the  pots  should  be  well  distributed  in  various  portions 
of  the  place  to  be  disinfected. 

Use  5  pounds  per  looo  cubic  feet  where  a  germicidal  action  is 
desired,  and  at  least  2  pounds  per  looo  cubic  feet  for  insecticidal 
purposes.  For  the  destruction  of  bacteria  an  exposure  of  from 
6  to  24  hours  is  necessiir>-,  while  for  the  destruction  of  vermin  from 
2  to  12  hours  is  sufficient,  depending  upon  the  size  and  shape  of 
the  compartment  to  be  treated.' 

STANDARDIZATION  OF  DISINFECTANTS 
Disinfectants  may  be  bacteriologically  standardized  by  the  method 
originated  by  Rideal  and  Walker,  and  modified  by  the  U.  S.  Hygienic 
Laboratory  and  others,  which  gives  the  strength  of  the  disinfectant  as 
compared  with  carbolic  acid  taken  as  a  standard.  The  figure  thus 
obtained  is  known  as  the  "carbolic  (or  phenol)  coefficient."  ^ 

Local  health  authorities  may  rely  upon  substances  of  known  value, 
but  if  there  is  any  question  or  a  new  disinfectant  is  to  be  adopted,  it 
should  be  tested  by  some  competent  authority,  such  as  a  state  labora- 
tory or  the  Hygienic  Laboratory  of  the  U.  S.  Public  Health  Service  at 
Washington.  The  latter  has  already  tested  a  number  of  commercial 
disinfectants,  some  of  which  were  found  to  have  little  or  no  value 
(Bull.  no.  82).  The  question  of  expense  also  enters  in,  and  the  cost  of 
the  commercial  preparation  in  question,  even  though  efficient,  should  be 
compared  with  that  of  the  ordinary  disinfecting  substances. 

HOUSEHOLD   DISINFECTANTS  AND   DEODORANTS 
A  number  of  commercial  preparations  are  sold  as  "household  disin- 
fectants," being  alleged  to  free  the  house  in  a  general  way  from  infec- 
tion.    It  scarcely  needs  be  repeated  that  the  best  prophylactic  measure 

^  Reprinted  from  Rosenau,  "Preventive  Medicine  and  Hygiene," 
19131  PP-  997  ff-  (where  other  methods  are  also  described),  by  permis- 
sion of  D.  Appleton  and  Company.  Copyright,  1913,  by  D.  Appleton 
and  Company. 

2  See  Rosenau,  "Preventive  Medicine  and  Hygiene,"  1913,  p.  974; 
Anderson  and  McClintock,  Method  of  Standardizing  Disinfectants 
with  and  without  Organic  Matter,  with  determination  of  the  phenol 
coefficient  of  some  commercial  disinfectants,  Bull.  no.  82,  Hyg.  Lab., 
Wash.,  1912;  Worth  Hale,  Method  for  Determining  the  Toxicity  of 
Coal-tar  Disinfectants,  with  report  on  relative  toxicity  of  some  com- 
mercial disinfectants.  Bull.  no.  88,  Hyg.  Lab.,  Wash.;  and  papers  and 
reports  of  special  Committee  in  Am.  Jour.  Pub.  Health  for  1912,  et 
seqq.  The  matter  is  now  in  the  hands  of  an  international  committee 
appointed  at  the  International  Congress  of  Hygiene  and  Demography 
and  International  Congress  of  Applied  Chemistry  in  1912. 


APPENDIX   A  591 

of  general  availability  is  domestic  cleanliness,  —  avoiflance  of  dissemi- 
nation of  filth,  and  a  plentiful  use  of  soap  and  water  supplemented  by 
air  and  sunlight.  Under  normal  circumstances  and  excejit  as  ordered 
by  health  authorities  it  is  jjractically  unnecessary  to  keep  powerful 
chemical  disinfectants  in  the  house,  and  some  (as  bichloride  of 
mercury)  are  poisonous.  Where  antiseptics  are  needed  coal-tar  sub- 
stances (cresols),  being  comparatively  non-poisonous,  may  be  used. 
Money  should  not  be  wasted  on  worthless  "household  disinfectants," 
a  number  of  which  are  on  the  market. 

The  absurd  idea  that  aromatic  vapors  or  disinfectants  placed  in 
saucers  about  a  sick-room  purify  the  air  should  be  dcfjrecated  as  a 
fetish,  distracting  attention  from  matters  of  real  importance.  Any 
needful  purification  of  the  air  can  be  accomplished  by  cleanliness  and 
airing.  Instead  of  neglecting  cleanliness  and  attempting  to  mask, 
neutralize  or  absorb  foul  odors  by  the  use  of  "disinfectants,"  they 
should  be  traced  to  their  source  and  the  latter  removed,  or,  if  necessary, 
treated  as  mentioned  below. 

Under  certain  circumstances,  when  freedom  from  bad  odors  in  and 
about  toilet  fixtures,  garbage  pails,  cellars,  etc.,  cannot  be  entirely 
secured  by  measures  of  cleanliness,  the  use  of  a  deodorant  is  justifiable. 
Chloride  of  lime  acts  as  a  deodorant  as  well  as  a  disinfectant.  The 
odor  of  chlorine  which  it  emits  is,  however,  disagreeable  to  sensitive 
noses. 

A  common,  cheap  and  effective  deodorant  is  lime.  The  use  of  lime 
(or  any  other  deodorant)  in  the  form  of  powder  is  not  satisfactory  for 
the  reason  that  a  thorough  admixture  with  the  substance  to  be  deodor- 
ized frequently  cannot  readily  be  secured.  Ordinary  whitewash  or 
milk  of  lime  made  from  freshly  burnt  quicklime  is  a  good  deodorant 
as  well  as  a  disinfectant.  Glue  is  frequently  added  to  whitewash  to 
increase  its  adhesiveness. 

Lime  combined  with  copper  is  even  more  effective.  Doty  recom- 
mends a  formula  of  one  pound  of  copper  sulphate  ("blue  vitriol,"  not 
"copperas"),  one  pound  of  unslaked  lime  ("rock-lime")  and  ten 
gallons  of  water,  which  may  be  prepared  as  follows  at  a  cost  of  about 
eight  cents  per  ten  gallons: 

In  preparing  the  mixture  ...  it  is  advisable  to  first  dissolve 
the  copper  by  placing  it  in  a  linen  bag  suspended  by  a  string  just 
below  the  surface  of  the  water.  In  this  way  it  is  dissolved  much 
more  rapidly  than  when  the  copper  is  thrown  in  the  bottom  of 
the  receptacle  and  stirred.  For  example,  the  copper  may  be  dis- 
solved in  six  or  eight  gallons  of  water,  leaving  the  remainder  of  the 
ten  gallons  to  prepare  the  lime,  which  is  done  by  placing  the 
latter  dry  in  the  pail  or  other  receptacle  and  gradually  adding 


592  A  MANUAL   FOR  HEALTH  OFFICERS 

,    water  and  stirring  until   the  "steaming"  or  "slaking"  is  com- 
pleted.    The  lime  is  then  gradually  added  to  the  water  in  which 
the  copper  has  already  been  dissolved,  the   mixture  being  con- 
stantly stirred  during  this  lime;  a  precipitation  then  takes  place. 
In  a  tightly-covered  receptacle  the  mixture  may  be  kept  indefi- 
nitely as  a  stock  solution,  always  to  be  well  stirred  before  using. ^ 
The  deodorizing  principle  exists  in  the  precipitate,  hence  the  mixture 
must  be  kept  stirred  during  use.     It  may  be  applied  with  brush  or 
sprinkling  pot  with  enlarged  holes  in  the  nozzle.     Offensive  liquids  may 
be  deodorized  by  admixture  of  the  lime-copper  solution  in  the  pro- 
portion of  one  gallon  to  30  to  50  gallons,  estimated. 

As  a  safe  and  simple  household  deodorant  about  woodwork  and  the 
like  formalin  may  be  used.  It  has  the  further  advantage  of  being  a 
germicide.  Formalin  may  be  obtained  in  small  ([uaiitities  from  any 
druggist.  It  should  be  kept  in  a  cool,  dark  place.  It  is  inexpensive 
if  diluted  and  sparingly  used,  little  being  necessary  for  deodorization. 

INSECTICIDES 

For  sulphur,  which  is  the  best  general  fumigant  for  insects,  see  page 
588. 

For  killing  mosquitoes  in  houses  where  sulphur  fumes  would  be  ob- 
jectionable Mim's  culicide,  composed  of  equal  parts  of  phenol  crystals 
and  camphor  thoroughly  combined,  is  useful.  The  material  is  evapo- 
rated from  an  earthenware  basin  over  an  alcohol  lamp,  in  the  amount 
of  4  ounces  per  thousand  cubic  feet.  If  necessary,  use  several  sets  of 
apparatus,  —  not  more  than  8  or  10  ounces  to  each.  The  space  should 
be  left  closed  for  at  least  one,  and  better,  two  hours.  Care  should  be 
taken  that  the  compound  does  not  catch  fire,  the  basin  being  placed  at 
a  proper  distance  above  the  flame.  The  apparatus  should  be  placed  in 
a  pan  containing  half  an  inch  of  water,  and  previous  experiments  should 
be  made  to  assure  safe  and  proper  working.  A  ventilated  support  for 
the  evaporating  basin,  made  of  a  section  of  stove  pipe,  is  a  useful 
adjunct  as  a  protection  against  drafts.  The  fumes  do  not  afTect  metals, 
fabrics  and  paints  as  does  sulphur,  though  varnishes  may  be  softened. 
They  are  somewhat  irritating  but  not  especially  poisonous.  The  insects 
are  stunned  but  not  always  killed;  hence  they  should  be  swept  up  and 
burned  directly  after  the  fumigation. 

In  all  insecticidal  fumigation  the  apartment  should  be  sealed  as  com- 
pletely as  possible  (see  page  577  f.)  and  crevices  and  folds  in  fabrics,  etc., 
where  the  insects  may  escape  or  take  cover,  should  be  stopped  up  or  re- 
moved. If  all  windows  are  covered  but  one,  the  insects  will  seek  the 
light  and  tend  to  collect  there. 

'  "Prevention  of  Infectious  Diseases,"  191 1,  pp.  202-09. 


APPENDIX  A  593 

REFERENCES 

A  detailed  discussion  of  disinfection  theory  and  methods,  also  of 
insect  extermination,  will  be  found  in  Rosenau's  "Preventive  Medicine 
and  Hygiene,"  1913,  upon  which  many  of  the  statements  in  the  fore- 
going condensed  treatment  of  the  subject  are  based. 

Cf.  also:  Doty,  "Prevention  of  Infectious  Diseases,"  191 1;  Whipple, 
"Typhoid  Fever,"  1908  (appendix). 


APPENDIX  B 

STANDARD    RULES   FOR  THE  PRODUCTION, 

HANDLING  AND   DISTRIBUTION 

OF   MILK 

(Commission  on  Milk  Standards  of  the  New  York  Milk  Committee, 

1913)' 

As  a  basis  for  the  promulgation  of  rules  and  recommendations  gov- 
erning the  production,  handling  and  distribution  of  milk,  it  is  recog- 
nized that  we  have  to  deal  with  two  kinds  of  milk,  raw  and  pasteurized, 
although  there  may  be  several  grades  of  each  of  these  two  kinds.  In 
order  for  any  grade  to  be  safe,  it  is  recommended  that  the  regula- 
tions herein  set  forth  under  the  heading  "Requirements  "  be  enforced. 
The  regulations  herein  set  forth  under  the  heading  "  Recommenda- 
tions "  should  be  adopted  wherever  practicable  as  a  means  of  improving 
the  milk  supply  above  the  actual  point  of  safety.  (The  term  "  milk  " 
shall  be  construed  to  include  the  fluid  derivatives  of  milk  wherever 
such  construction  of  the  term  is  applicable.) 

LICENSES 

Requirements 

No  person  shall  engage  in  the  sale,   handling,  or  distribution  of 

milk  in until  he  has  obtained  a  license  therefor  from  the  health 

authorities.     This  license  shall  be  renewed  on  or  before  the  ist  day  of 
of  each  year  and  may  be  suspended  or  revoked  at  any  time  for 

cause. 

Recommendations 

The  application  for  the  license  shall  include  the  following  statements: 

(1)  Kind  of  milk  to  be  handled  or  sold. 

(2)  Names  of  producers  with  their  addresses  and  permit  numbers. 

(3)  Names  of  middlemen  with  their  addresses. 

'  This  entire  Appendix  is  reprinted  from  Reprint  No.  141  from  the 
Public  Health  Reports,  U.  S.  Public  Health  Ser\'ice,  Aug.  22,  1913. 
The  committee  holds  frequent  meetings,  and  additional  resolutions 
are  recorded  in  its  annual  reports  published  in  the  Public  Health 
Reports. 

594 


APPENDIX  B  595 

(4)  Names  and  addresses  of  all  stores,  hotels,  faclories  and  restau- 
rants at  which  milk  is  delivered. 

(5)  A  statement  of  the  ai)i)roximate  nimihiT  of  f|uarls  of  milk,  cream, 
buttermilk  and  skim  milk  sold  per  day. 

(6)  Source  of  water  supply  at  farms  and  bottling  plants. 

(7)  Permission  to  inspect  all  local  and  out-of-town  |)remises  on 
which  milk  is  produced  and  handled. 

(8)  Agreement  to  abide  by  all  the  provisions  of  State  and  local 
regulations. 

PERMITS 

Requirements 

No  person  shall  engage  in  the  production  of  milk  for  sale  in ,  nor 

shall  any  person  engage  in  the  handling  of  milk  for  shipment  into 

until  he  has  obtained  a  permit  therefor  from  the  health  authorities. 

This  permit  shall  be  renewed  on  or  before  the  ist  day  of of  each 

year  and  may  be  suspended  or  revoked  at  any  time  for  cause. 

I.   RAW  MILK 

COW  STABLES 
Requirements 

1.  They  shall  be  used  for  no  other  purpose  than  for  the  keeping  of 
cows,  and  shall  be  light,  well  ventilated  and  clean. 

2.  They  shall  be  ceiled  overhead  if  there  is  a  loft  above. 

3.  The  floors  shall  be  tight  and  sound. 

4.  The  gutters  shall  be  water-tight. 

Recom^neiidations 

1.  The  window  area  shall  be  at  least  2  square  feet  per  500  cubic 
feet  of  air  space  and  shall  be  uniformly  distributed,  if  possible.  If 
uniform  distribution  is  impossible,  sufficient  additional  window  area 
must  be  provided  so  that  all  portions  of  the  barn  shall  be  adequately 
lighted. 

2.  The  amount  of  air  space  shall  be  at  least  500  cubic  feet  per  cow, 
and  adequate  ventilation  besides  windows  shall  be  provided. 

3.  The  walls  and  ceilings  shall  be  whitewashed  at  least  once  every 
six  months,  unless  the  construction  renders  it  unnecessary',  and  shall 
be  kept  free  from  cobwebs  and  dirt. 

4.  All  manure  shall  be  removed  at  least  twice  daily,  and  disposed 
of  so  as  not  to  be  a  source  of  danger  to  the  milk  either  as  furnishing 
a  breeding  place  for  flies  or  otherwise. 

5.  Horse  manure  shall  not  be  used  in  the  cow  stable  for  any  purpose. 


596  A  MANUAL   FOR   HEALTH  OFFICERS 

MILK   ROOM 
Requirements 

Every  milk  farm  shall  be  provided  with  a  milk  room  that  is  clean, 
light  and  well  screened.  It  shall  be  used  for  no  other  purpose  than 
for  the  cooling,  bottling  and  storage  of  milk  and  the  operations  inci- 
dent thereto. 

Recommendalions 

1.  It  shall  have  no  direct  connection  with  any  stable  or  dwelling. 

2.  The  floors  shall  be  of  cement  or  other  impervious  material, 
properly  graded  and  drained. 

3.  It  shall  be  provided  with  a  sterilizer  unless  the  milk  is  sent  to  a 
bottling  plant,  in  which  case  the  cans  shall  be  sterilized  at  the  plant. 

4.  Cooling  and  storage  tanks  shall  be  drained  and  cleaned  at  least 
twice  each  week. 

5.  All  drains  shall  discharge  at  least  100  feet  from  any  milk  house 
or  cow  stable. 

COWS 
Requirements 

1.  A  physical  examination  of  all  cows  shall  be  made  at  least  once 
every  six  months  by  a  veterinarian  approved  by  the  health  authorities. 

2.  Every  diseased  cow  shall  be  removed  from  the  herd  at  once  and 
no  milk  from  such  cows  shall  be  offered  for  sale. 

3.  The  tuberculin  test  shall  be  applied  at  least  once  a  year  by  a 
veterinarian  approved  by  the  health  authorities. 

4.  All  cows  which  react  shall  be  removed  from  the  herd  at  once, 
and  no  milk  from  such  cows  shall  be  sold  as  raw  milk. 

5.  No  new  cows  shall  be  added  to  a  herd  until  they  have  passed  a 
physical  examination  and  the  tuberculin  test. 

6.  Cows,  especially  the  udders,  shall  be  clean  at  the  time  of  milking. 

7.  No  milk  that  is  obtained  from  a  cow  within  15  days  before  or  5 
days  after  parturition,  nor  any  milk  that  has  an  unnatural  odor  or 
appearance,  shall  be  sold. 

8.  No  unwholesome  food  shall  be  used. 

Recommendatiojts 

1.  Every  producer  shall  allow  a  veterinarian  employed  by  the 
health  authorities  to  examine  his  herd  at  any  time  under  the  penalty 
of  having  his  supply  excluded. 

2.  Certificates  showing  the  results  of  all  examinations  shall  be  filed 
with  the  health  authorities  within  10  days  of  such  examinations. 


APPENDIX  B  597 

3.  The  tuberculin  tesls  shall  be  ,ii)|)lifjfj  at.  least  once  every  six  months 
by  a  veterinarian  approved  by  the  health  authorities,  unless  on  the  last 
previous  test  no  tuberculosis  was  present  in  the  herd  or  in  the  herds 
from  which  new  cows  were  obtainetl,  in  which  event  the  test  may  be 
postponed  an  additional  six  months. 

4.  Charts  showing  the  results  of  all  tuberculin  tests  shall  Ik-  filed 
with  the  health  authorities  within  ID  days  of  the  date  of  such  test. 

5.  The  udders  shall  be  washed  and  wiped  before  milking. 

EMPLOYEES 
Requirements 

1.  All  employees  connected  in  any  way  with  the  production  and 
handling  of  milk  shall  be  personally  clean  and  shall  wear  clean  outer 
garments. 

2.  The  health  authorities  shall  be  notified  at  once  of  any  communi- 
cable disease  in  any  person  that  is  in  any  way  connected  with  the 
production  or  handling  of  milk,  or  of  the  exposure  of  such  person  to 
any  communicable  disease. 

3.  Milking  shall  be  done  only  with  dry  hands. 

Recommendations 

1.  Clean  suits  shall  be  put  on  immediately  before  milking. 

2.  The  hands  shall  be  washed  immediately  before  milking  each  cow, 
in  order  to  avoid  conveyance  of  infection  to  the  milk. 

UTENSILS 
Requirements 

1.  All  utensils  and  apparatus  with  which  milk  comes  in  contact 
shall  be  thoroughly  washed  and  sterilized,  and  no  milk  utensil  or 
apparatus  shall  be  used  for  any  other  purpose  than  that  for  which  it 
was  designed. 

2.  The  owner's  name,  license  number,  or  other  identification  mark, 
the  nature  of  which  shall  be  made  known  to  the  health  authorities, 
shall  appear  in  a  conspicuous  place  on  every  milk  container. 

3.  No  bottle  or  can  shall  be  removed  from  a  house  in  which  there 
is,  or  in  which  there  has  recently  been,  a  case  of  communicable  disease 
until  permission  in  writing  has  been  granted  by  the  health  authorities. 

4.  All  metal  containers  and  piping  shall  be  in  good  condition  at  all 
times.  All  piping  shall  be  sanitar>^  milk  piping,  in  couples  short  enough 
to  be  taken  apart  and  cleaned  with  a  brush. 

5.  Small-top  milking  pails  shall  be  used. 


598  A  MANUAL   FOR  HEALTH  OFFICERS 

Recommendations 

1.  All  cans  and  bottles  shall  be  cleaned  as  soon  as  possible  after 
being  emptied. 

2.  Every  conveyance  used  for  the  transportation  or  delivery  of 
milk,  public  carriers  excepted,  shall  bear  I  lie  owner's  name,  milk-license 
number  and  business  address  in  uncondensed  gothic  characters  at  least 
2  inches  in  height. 

MILK 

Requirements 

1.  It  shall  not  be  strained  in  the  cow  stable,  but  shall  be  removed 
to  the  milk  room  as  soon  as  it  is  drawn  from  the  cow. 

2.  It  shall  be  cooled  to  50°  F.  or  below  within  two  hours  after  it  is 
drawn  from  the  cow  and  it  shall  be  kept  cold  until  it  is  delivered  to  the 
consumer. 

3.  It  shall  not  be  adulterated  by  the  addition  to  or  the  subtraction 
of  any  substance  or  compound,  except  for  the  production  of  the  fluid 
derivatives  allowed  by  law. 

4.  It  shall  not  be  tested  by  taste  at  any  bottling  plant,  milk  house, 
or  other  place  in  any  way  that  may  render  it  liable  to  contamination. 

5.  It  shall  be  bottled  only  in  a  milk  room  or  bottling  plant  for 
which  a  license  or  permit  has  been  issued. 

6.  It  shall  be  delivered  in  bottles,  or  single  service  containers,  with 
the  exception  that  20  quarts  or  more  may  be  delivered  in  bulk  in  the 
following  cases: 

(a)  To  establishments  in  which  milk  is  to  be  consumed  or  used  on 
the  premises. 

{b)  To  infant-feeding  stations  that  are  under  competent  medical 
superv-ision. 

7.  It  shall  not  be  stored  in  or  sold  from  a  living  room  or  from  any 
other  place  which  might  render  it  liable  to  contamination. 

Recommendations 

1.  It  shall  be  cooled  to  50°  F.  or  below  immediately  after  milking 
and  shall  be  kept  at  or  below  that  temperature  until  it  is  delivered  to 
the  consumer. 

2.  It  shall  contain  no  visible  foreign  material. 

3.  It  shall  be  labeled  with  the  date  of  production. 

RECEIVING   STATIONS   AND   BOTTLING   PLANTS 

Requirements 

I.  They  shall  be  clean,  well  screened  and  lighted,  and  shall  be  used 
for  no  other  purpose  than  the  proper  handling  of  milk  and  the  opera- 


APPENDIX   B  599 

tions  incident  thereto,  and  shall  be  open  to  insjjection  ijy  the  health 
anthorities  at  any  time. 

2.  They  shall  have  smooth,  impervious  floors,  properly  grafled  and 
drained. 

3.  They  shall  be  ecjuipped  with  hot  and  cold  water  anfl  steam. 

4.  Ample  provision  shall  be  marie  for  steam  sterilization  of  all 
utensils,  and  no  cmply  milk  containers  shall  be  sent  ont  until  after 
such  sterilization. 

5.  All  utensils,  pii)iny;  and  tanks  shall  be  kejjl  clean  and  shall  be 
sterilized  daily. 

Recom  me  ndatio  ns 

I.  Containers  and  utensils  shall  not  be  washed  in  the  same  room  in 
which  milk  is  handled. 

STORES 
Requirements 

1.  All  stores  in  which  milk  is  handled  shall  be  provided  with  a  suit- 
able room  or  compartment  in  which  the  milk  shall  be  kept.  Said 
compartment  shall  be  clean  and  shall  be  so  arranged  that  the  milk  will 
not  be  liable  to  contamination  of  any  kind. 

2.  Milk  shall  be  kept  at  a  temperature  not  exceeding  50°  F. 

Recommendations 

I.  Milk  to  be  consumed  ofT  the  premises  may  be  sold  from  stores 
only  in  the  original  unopened  package. 

GENERAL   REGULATIONS 
Requirements 

1.  The  United  States  Bureau  of  Animal  Industry  score  card  shall 
be  used,  and  it  is  recommended  that  dairies  from  which  milk  is  to  be 
sold  in  a  raw  state  shall  score  at  least  80  points. 

2.  Every  place  where  milk  is  produced  or  handled  and  everj'  con- 
veyance used  for  the  transportation  of  milk  shall  be  clean. 

3.  All  water  supplies  shall  be  from  uncontaminated  sources  and 
from  sources  not  liable  to  become  contaminated. 

4.  The  license  or  permit  shall  be  kept  posted  in  a  conspicuous  place 
in  every  establishment  for  the  operation  of  which  a  milk  license  or 
permit  is  required. 

5.  No  milk  license  or  permit  shall  at  any  time  be  used  by  any  per- 
son other  than  the  one  to  whom  it  was  granted. 

6.  No  place  for  the  operation  of  which  a  license  or  permit  is  granted 
shall  be  located  within  100  feet  of  a  priv}'  or  other  possible  source  of 


6oo  A   MANUAL  FOR  HEALTH  OFFICERS 

contamination,  nor  shall  it  contain  or  open  into  a  room  which  contains 
a  water-closet. 

7.  No  skim  milk  or  buttermilk  shall  be  stored  in  or  sold  from  cans 
or  other  containers  unless  such  containers  arc  of  a  distinctive  color 
and  permanently  and  conspicuously  labeled  "  skim  milk  "  or  "  butter- 
milk," as  the  case  may  be. 

8.  No  container  shall  be  used  for  any  other  purpose  than  that  for 
which  it  is  labeled. 

Recommendations 

1.  Ice  used  for  cooling  purposes  shall  be  clean  and  uncontaminated. 

2.  No  person  whose  presence  is  not  retiuired  shall  be  permitted  to 
remain  in  any  cow  stable,  milk  house  or  bottling  room. 

SUBNORMAL  MILK 
Requirements 
I.  Natural  milk  that  contains  less  than  3.25  per  cent,  but  more 
than  2.5  per  cent  milk  fat,  and  that  complies  in  all  other  respects  with- 
the  requirements  above  set  forth,  may  be  sold,  provided  the  percentage 
of  fat  does  not  fall  below  a  definite  percentage  that  is  stated  in  a  con- 
spicuous manner  on  the  container;  and  further  provided  that  such 
container  is  conspicuously  marked  "  substandard  milk." 

CREAM 
Requirements  and  Recommendations 

I.  It  shall  be  obtained  from  milk  that  is  produced  and  handled  in 
accordance  with  the  provisions  hereinbefore  set  forth  for  the  produc- 
tion and  handling  of  milk. 

STANDARDS   FOR   MILK 
Requirements 

1.  It  shall  not  contain  more  than  100,000  bacteria  per  cubic  centi- 
meter. 

2.  It  shall  contain  not  less  than  3.25  per  cent  milk  fat. 

3.  It  shall  contain  not  less  than  8.5  per  cent  solids  not  fat. 

Recommendations 
I.    The  bacterial  limit  shall  be  lowered  if  possible. 

STANDARDS   FOR   CREAM 
Requirements 

1.  There  shall  be  a  bacterial  standard  for  cream  corresponding  to 
the  grade  of  milk  from  which  it  is  made  and  to  its  butter-fat  content. 

2.  It  shall  contain  not  less  than  18  per  cent  milk  fat. 


APPENDIX  B  601 

Recommendalions 
Same  as  above  for  milk. 

STANDARDS  FOR   SKIM    MILK 
Requirements 

1.  It  shall  contain  not  less  than  8.75  ijcr  cent  milk  solids. 

2.  Control  of  sale  of  skim  milk:  Whether  skim  milk  is  sold  in 
wagons  or  in  stores  all  containers  holding  skim  milk  should  be  painted 
some  bright,  distinctive  color  and  prominently  and  legibly  marked 
"  skim  milk."  When  skim  milk  is  placed  in  the  buyer's  container,  a 
label  or  tag  bearing  the  words  "  skim  milk  "  should  be  attached. 

II.    PASTEURIZED   MILK 

Pasteurized  milk  is  milk  that  is  heated  to  a  temperature  of  not  less 
than  140°  F.  for  not  less  than  20  minutes,  or  not  over  155°  F.  for  not 
less  than  5  minutes,  and  for  each  degree  of  temperature  over  140°  F. 
the  length  of  time  may  be  i  minute  less  than  20.  Said  milk  shall  be 
cooled  immediately  to  50°  F.  or  below  and  kept  at  or  below  that  tem- 
perature. 

COW  STABLES 

Requirements  and  recommendations  same  as  for  raw  milk. 

MILK   ROOM 
Requirements  and  recommendations  same  as  for  raw  milk. 

COWS 

Requirements 

The  same  as  for  the  production  of  raw  milk,  with  the  exception  of 
the  sections  relating  to  the  tuberculin  test. 

Recotnmendations 

That  no  cows  be  added  to  a  herd  e.xcepting  those  found  to  be  free 
from  tuberculosis  by  the  tuberculin  test. 

EMPLOYEES 
Requirements  and  recommendations  same  as  for  raw  milk. 

UTENSILS 
Requirements  and  recommendations  same  as  for  raw  milk. 


6o2  A  MANUAL  FOR  HEALTH  OFFICERS 

MILK   FOR   PASTEURIZATION 
Requirements 

1.  The  same  as  for  the  production  of  raw  milk,  with  the  exception 
of  sections  i,  2  and  6b. 

2.  It  shall  be  cooled  to  6o°  F.  or  below  within  two  hours  after  it  is 
drawn  from  the  cow,  and  it  shall  be  held  at  or  below  that  temperature 
until  it  is  pasteurized.  After  pasteurization,  it  shall  be  held  at  a  tem- 
perature not  exceeding  50°  F.  until  delivered  to  the  consumer. 

3.  Pasteurized  milk  shall  be  distinctly  labeled  as  such,  together 
with  the  temperature  at  which  it  is  pasteurized  and  the  shortest  length 
of  exposure  to  that  temperature  and  the  date  of  pasteurization. 

Recommendations 

1.  No  milk  shall  be  repasteurized. 

2.  The  requirements  governing  the  production  and  handling  of 
milk  for  pasteurization  should  be  raised  wherever  practicable. 

PASTEURIZING    PLANTS 

Requirements 

The  same  as  under  "  Receiving  stations  and  bottling  plants  "  for 
raw  milk. 

Recommendations 

The  same  as  under  "  Receiving  stations  and  bottling  plants  "  for 
raw  milk. 

STORES 
Requirements  and  recommendations  same  as  for  raw  milk. 

GENERAL   REGULATIONS 
Requirements 

1.  It  is  recommended  that  dairies  producing  milk  which  is  to  be 
pasteurized  shall  be  scored  on  the  United  States  Bureau  of  Animal 
Industr>'  score  card,  and  that  health  departments,  or  the  controlling 
departments  whatever  they  may  be,  strive  to  bring  these  scores  up  as 
rapidly  as  possible. 

2.  Milk  from  cows  that  have  been  rejected  by  the  tuberculin  test, 
but  which  show  no  physical  signs  of  tuberculosis,  as  well  as  those  which 
have  not  been  tested,  may  be  sold  provided  that  it  is  produced  and 
handled  in  accordance  with  all  the  other  requirements  herein  set  forth 
for  pasteurized  milk. 

3.  Ice  used  for  cooling  purposes  shall  be  clean. 


APPKNFJIX   B  G03 

Recommendations 
The  same  as  for  raw  milk. 

PASTEURIZED   CREAM 
Requirements 

1.  It  shall  be  ()I)tainccl  only  from  milk  that  could  legally  be  sold  as 
milk  under  the  requirements  hereinbefore  set  forth. 

2.  Pasteurized  cream,  or  cream  separated  from  pasteurized  milk, 
shall  be  labeled  in  the  manner  herein  provided  for  the  labeling  of  pas- 
teurized milk. 

STANDARDS   FOR   PASTEURIZED   MILK 
Requirements 

1.  It  shall  not  contain  more  than  1,000,000  bacteria  per  cubic  centi- 
meter before  pasteurization,  nor  over  50,000  when  delivered  to  the  con- 
sumer. 

2.  The  standards  for  the  percentage  of  milk  fat  and  of  total  solids 
shall  be  the  same  as  for  raw  milk. 

Recommendations 

I.  The  limits  for  the  bacterial  count  before  pasteurization  and  after 
pasteurization  should  both  be  lowered  if  possible. 

STANDARDS  FOR   PASTEURIZED   CREAM 
Requirements 

1.  No  cream  shall  be  sold  that  is  obtained  from  pasteurized  milk 
that  could  not  be  legally  sold  under  the  provisions  herein  set  forth,  nor 
shall  any  cream  that  is  pasteurized  after  separation  contain  an  exces- 
sive number  of  bacteria. 

2.  There  shall  be  a  bacterial  standard  for  pasteurized  cream  corre- 
sponding to  the  grade  of  milk  from  which  it  is  made  and  to  its  butter- 
fat  content. 

3.  The  percentage  of  milk  fat  shall  be  the  same  as  for  raw  cream. 

PENALTY 
Every  milk  ordinance  should  contain  a  penalty  clause. 


APPENDIX   C 

LEGAL   DECISIONS   REGARDING  THE 
TUBERCULIN   TEST 

The  decision  of  the  Supreme  Court  of  New  Jersey  by  which  the  riglit 
of  the  Board  of  Health  of  Montclair,  N.  J.,  to  require  the  tubercuHn- 
testing  of  dairy  cattle  was  affirmed,  is  of  such  importance,  not  only  for 
its  bearing  upon  the  status  of  the  tuberculin  test  but  also  as  a  general 
comment  upon  the  powers  of  local  authorities  in  the  supervision  of 
food  supplies,  that  the  principal  points  of  the  decision  arc  here  given. ' 
Below  is  the  section  of  the  Sanitary  Code  of  Montclair  which  the 
company  contesting  the  regulation  sought  to  have  set  aside: 

"  No  milk  -  shall  be  sold  or  offered  for  sale  or  distributed  in  the 
town  of  Montclair  except  from  cows  in  good  health,  nor  unless  the 
cows  from  which  it  is  obtained  have  within  one  year  been  exam- 
ined by  a  veterinarian  whose  competency  is  vouched  for  by  the 
State  Veterinary  Association  of  the  State  in  which  the  herd  is 
located,  and  a  certificate  signed  by  such  veterinarian  has  been 
filed  with  the  board  of  health,  stating  the  number  of  cows  in  each 
herd  that  are  free  from  disease.  This  examination  shall  include 
the  tuberculin  test,  and  charts  showing  the  reaction  of  each  indi- 
vidual cow  shall  be  filed  with  this  board.  All  cows  which  react 
shall  be  removed  from  the  premises  at  once  if  the  sale  of  milk  is 
to  continue,  and  no  cows  shall  be  added  to  a  herd  until  a  certifi- 
cate of  satisfactory  tuberculin  tests  of  said  cows  have  been  filed 
with  this  board." 
(The  Board  had  previously  required  simply  physical  veterinary 
examinations.) 

1  For  further  details  see  Rpt.  Montclair  Board  of  Health  for  191 1 
(containing  complete  decision  and  review  of  case)  and  preceding  years 
back  to  1907,  when  the  contested  ordinance  was  adopted;  and  Wells, 
"  The  Successful  Efforts  of  a  Small  City  to  Secure  a  Milk  Supply  from 
Tuberculin-Tested  Cows,"  Afn.  Jour.  Pub.  Health,  1912,  vol.  ii,  no.  9, 
p.  702. 

^  Under  another  section  of  the  ordinance  the  same  requirements 
apply  to  cream. 

604 


APPENDIX   C  605 

By  an  amendment  adopted  a  little  later,  pasteurization  under  ron- 
ditions  proscriljed  by  the  Board  of  Health  was  allowed  as  a  substitute 
for  the  tuberculin  test. 

The  case  was  argued  before  the  State  Supreme  Court  in  191 1,  a 
large  mass  of  testimony  from  some  of  the  most  eminent  authorities  in 
the  country  being  taken,  and  every  point  at  issue  was  decided  in  favor 
of  the  Board  of  Health.  An  appeal  was  taken  by  the  company  to  the 
higher  court  of  Errors  and  Appeals,  but  was  later  withdrawn,  so  that 
the  legal  status  of  the  tuberculin-test  reriuirenicnt  reverted  to  the 
Supreme  Court  decision  and  the  ordinance  became  effective.  By  its 
firmness  and  persistency  in  upholding  its  case,  which,  moreover,  re- 
quired large  legal  expenditures,  the  Montclair  Board  of  Health  thus 
finally  succeeded  in  establishing  the  legal  basis  for  the  statement  of 
its  Health  Officer  that  "  with  the  present-day  knowledge  of  the  rela- 
tion between  bovine  and  human  tuberculosis  any  board  of  health  that 
does  not  require  the  tuberculin  test,  or  pasteurization  of  the  milk  as  an 
alternative,  must  be  considered  negligent." 

Below  (somewhat  rearranged)  are  the  chief  points  In  the  summary 
of  the  Supreme  Court  decision. 

1.  Boards  of  Health  are  empowered  by  the  act  of  1897  (P.  L. 
270),  and  by  the  Pure  Food  Law  of  1907  (P.  L.  485),  taken  in  con- 
junction with  the  act  of  1887  (P.  L.  80),  to  prohibit  the  sale  of 
milk  from  diseased  cows. 

2.  Whether  cows  from  which  a  municipality  is  supplied  with 
milk  are  diseased.  Is  a  question  that  may,  In  the  first  Instance,  be 
determined  by  the  local  board  of  health. 

3.  In  determining  whether  cows  from  which  a  municipality  Is 
supplied  with  milk,  are  diseased,  the  method  of  diagnosis  adopted 
by  the  local  board  of  health  should  be  one  that  Is  well  recognized, 
thoroughly  approved,  and  as  reliable  as  any. 

4.  A  local  board  of  health  may  prohibit  the  sale  within  the 
municipality  of  milk  from  cows  that  react  to  the  "  tuberculin  test." 

(The  following  considerations  relate  particularly  to  the  value  of  the 
tuberculhi  test) : 

7.  We  find  that  the  tuberculin  test  Is  the  most  reliable  method 
of  diagnosis  of  tuberculosis  in  cattle  now  known;  that  while  It  Is 
not  perfect,  the  percentage  of  error  is  as  small  as  In  any  method 
suggested,  and  that  it  Is  more  accurate  than  the  method  by  physi- 
cal examination.  We  rest  this  conclusion  not  merely  upon  the 
testimony  In  the  case  but  upon  the  fact  that  It  has  been  approved 
by  judicial  decision  in  Minnesota,  Louisiana,  Wisconsin  and  Penn- 
sylvania, and  adopted  by  the  most  recent  statute  in  Delaware, 
Indiana,   Maryland,   Michigan,   Minnesota,   New  Mexico,   North 


6o6  A  MANUAL  FOR   HIOALTH   OFFICERS 

"Dakota,  Oregon,  Pennsylvania,  South  Carolina,  Tennessee,  Wash- 
ington and  Wisconsin,  and  for  some  purposes  by  Maine,  Massa- 
chusetts and  V'ermont.  The  "  tuberculin  test  "  referred  to  in 
the  act  of  South  Dakota  is  probably  the  same.  A  similar  act  was 
passed  by  our  own  Legislature  in  1899  (P.  L.,  484).  These  stat- 
utes are  legislative  testimony  of  cumulative  force  to  the  value  of 
the  tuberculin  test  as  a  diagnostic  agent.  We  think,  therefore, 
that  the  board  of  health  is  justified  in  the  position  that  the  cattle 
which  react  to  the  tuberculin  test  are  diseased.  That  conclusion 
may  occasionally  be  erroneous,  but  it  is  as  nearly  accurate  as  is 
possible.  The  statute  empowers  the  board  of  health  to  prohibit 
the  sale  of  milk  from  such  cattle. 

8.  It  seems  to  be  established  that  there  is  very  little  chance 
of  communication  of  bovine  tuberculosis  to  human  beings  above 
the  age  of  sixteen  years,  but  that  there  is  very  serious  danger  of 
communication  through  the  medium  of  milk  to  human  beings 
under  the  age  of  sixteen  years  of  age  and  especially  to  children 
under  five  years  of  age.  It  is  conceded  that  there  are  such  cases. 
The  concession  that  bovine  tuberculosis  may  be  communicated  to 
young  children  and  that  although  it  appears  in  them  in  the  less 
common  form  rather  than  in  the  form  of  pulmonary'  tuberculosis, 
suffices  to  justify  action  to  guard  the  young  against  the  contagion. 
It  is  for  the  board  of  health  to  decide  how  many  lives  must  be 
endangered,  and  whether  the  lives  of  a  few  infants  or  children  are 
worth  the  effort  and  the  financial  loss. 

9.  The  evidence  justifies  a  finding  that  the  subjection  of  the 
cows  from  which  a  supply  of  milk  is  derived  to  the  tuberculin 
test  is  a  reasonable  method  of  determining  not  only  whether  they 
are  diseased  but  also  whether  their  milk  may  carry  the  germs  of 
tuberculosis. 

ID.  Surely  milk  from  cattle  that  react  to  a  tuberculin  test,  has 
been  exposed  to  disease,  and  if  the  cattle  themselves  may  be  kept 
out  of  the  state,  it  is  fairly  within  the  discretion  confided  in  boards 
of  health  to  exclude  also  milk,  the  produce  of  the  cattle,  which  it  is 
proved  may  at  times  convey  the  disease. 
(The  following  have  a  general  bearing  on  the  powers  of  health  authori- 
ties): 

5.  The  action  of  a  local  board  in  adopting  measures  for  the 
protection  of  public  health  will  not  be  set  aside  by  the  court  if  the 
board  has  acted  reasonably  upon  evidence  that  might  satisfy  a 
reasonable  man. 

6.  Regulations  for  the  protection  of  the  public  health  are  within 
the  police  power  of  the  state  and  are  not  an  illegal  interference 


APPENDIX  C  607 

with  interstate  commerce  if  they  have  a  real  substantial  relation 

to  a  public  object  which  government  can  accomplish,  and  are  not 

arbitrary  and  unreasonable  and  beyond  the  necessities  of  the  case. 

More  recently  a  tuberculin  test  ordinance  of  the  Milwaukee  Board 

of  Health  has  been  upheld  by  the  United  States  Supreme  Court,'  so 

that  the  legal  status  of  the  test  is  now  practically  established  beyond 

question. 

A  tuberculin-test  ordinance  of  Los  Angeles,  Cal.,  was  defeated  in 
1912  by  a  popular  referendum  vote.-  This,  however,  it  is  to  be  pre- 
sumed, has  no  bearing  upon  the  legal  status  of  the  test  itself. 

*  Am.  Jour.  Pub.  Health,  1913,  vol.  iii,  no.  8,  p.  837. 

2  Am.  Jour.  Pub.  Health,  1912,  vol.  ii,  no.  7,  p.  586  and  editorial. 


APPENDIX  D 
THE  HEALTH  DEPARTMENT  LABORATORY 

The  necessity  of  laboratory  facilities  in  modern  public  health  work 
has  been  brought  out  in  the  foregoing  pages;  also  the  fact  that  such 
facilities  should  be  as  near  at  hand  as  possible.  The  local  laboratory 
is  for  most  purposes  the  ideal,  provided  expert  service  is  available. 
State  laboratories  are  useful,  especially  as  they  may  command  the 
services  of  experts  who  devote  their  entire  time  to  laboratory  work 
while  local  bacteriologists  may  be  employed  for  so  few  examinations 
that  their  practice  does  not  keep  up  to  par  with  the  latest  and  best 
methods.  But  the  disadvantage  is  that  the  state  laboratory  is  usually 
at  some  distance,  and  the  delay  in  transmitting  specimens  and  obtaining 
results  is  a  serious  drawback  in  this  class  of  work. 

The  functions  of  the  laboratory  include  bacteriological  and  serum 
diagnosis  (diphtheria,  typhoid  fever,  tuberculosis,  etc.),  bacteriological 
and  chemical  work  on  milk  and  perhaps  other  foods,  bacteriological 
tests  of  water-supplies  (the  chemical  tests  are  beyond  the  range  of  the 
usual  local  laboratory),  the  keeping  and  distribution  of  antitoxins  and 
other  sera,  etc.  Every  health  department  should  perform,  or  arrange  to 
have  performed,  every  kind  of  laboratory  service  required  in  public  health 
work.  Thus  routine  examinations  may  be  made  locally,  while  if  neces- 
sary unusual  kinds  of  work  may  be  transmitted,  by  arrangement,  to  a 
state  or  completely  equipped  city  laboratory. 

Since  as  much  local  work  as  possible  should  be  done,  and  boards  of 
health  in  small  towns  are  frequently  unable  to  afford  to  pay  for  the 
necessary  installation  and  services,  it  is  highly  desirable  that  several 
neighboring  towns  combine  in  the  maintenance  of  a  joint  laboratory 
and  bacteriologist.  Sometimes  such  a  laboratory  can  be  run  in  con- 
nection with  a  hospital  requiring  the  services  of  a  diagnostic  bacteri- 
ologist. Where  the  valuable  plan  of  a  joint  health  office  (see  Appen- 
dix F)  is  in  operation,  the  joint  laboratory  is  a  natural  part  of  the 
scheme.  Where  two  or  more  communities  are  thus  linked  together,  — 
and  even  in  single  towns  covering  rather  a  large  area, — arrangements 
may  be  made  for  several  culture  stations,  e.g.,  in  drug  stores,  where 
outfits  may  be  secured  and  specimens  left  for  collection  and  trans- 
mission to  the  laboratory  at  regular  hours. 

608 


APPENDIX  D  C09 

The  following  lisl  of  laboratory  equipment  for  a  small  board  of  health 
laboratory,  for  diagnostic  work,  and  examination  of  milk  and  water, 
with  approximate  costs,  is  taken  from  the  paper  by  E.  13.  Phelps, 
quoted  in  Appendix  F.  In  the  installation  of  such  a  laboratory  possible 
expenses  for  plumbing,  gas  piping,  electric  wiring,  benches,  cabinets, 
and  other  carpentering,  refrigerator,  anrl  the  like  shouUl  be  considered. 
To  the  list  should  also  be  added  the  cost  (foo  or  $40)  of  hot  air  and 
steam  (Arnold)  sterilizers.  Exact  costs  may  be  figured  by  consulting 
the  catalogues  of  the  laboratory  supply  companies,  some  of  which 
make  a  discount  from  their  list  prices.  Once  such  a  laboratory  has 
been  installed  the  running  expenses  are  moderate. 

Analytical  balance $125.00 

Babcock  machine  and  accessories,  with  special  sedi- 
ment head 100. 00 

Incubator 125.00 

Microscope  and  accessories 125 .  00 

I  gross  diphtheria  outfits,  complete 1500 

I  gross  typhoid  and  malaria  outfits,  complete 10.00 

6  dozen  sputum  outfits,  complete 5-  00 

I  gross  ophthalmia  loops 5  •  00 

Glassware  (see  schedule) 150. 40 

Chemicals  (see  schedule) 22.  35 

Miscellaneous  (see  schedule) 78. 00 

Total $760.75 

Glassware 

200  Petri  dishes. 

100  I -cubic-centimeter  pipettes. 

100  8-ounce  bottles  for  dilutions. 

ID  gross  6-inch  test  tubes  for  media. 

I  counting  plate. 

I  gross  microscope  slides. 

1  dozen  4-ounce  stain  bottles. 

2  Liebig  condensers,  25  inches. 
6  I -liter  round-bottom  flasks. 

6  graduated  cylinders,  100  cubic  centimeters,  250  cubic  centimeters, 

and  I  liter. 
6  50-cubic-centimeter  burettes,  glass  stoppered. 
6  250-cubic-centimeter  evaporating  dishes. 
2  pounds  glass  stirring  rod. 
12  Nessler  jars,  50  cubic  centimeters. 
I  gross  8-ounce  reagent  bottles. 


6lO  A  MANUAL   FOR  HEALTH  OFFICERS 

Chemicals 

8  pounds  acid,  sulphuric. 
6  pounds  acid,  hydrochloric. 
I  pound  acid,  acetic. 
I  pound  acid,  nitric. 
I  pound  acid,  oxalic. 
5  [pounds  alcohol. 

4  ounces  amidonaphthalene. 

I  pound  ammonium  chloride. 

I  pound  copper  sulphate. 

I  pound  ether. 

I  ounce  ferrous  ammonium  sulphate. 

I  pound  lead  acetate. 

I  pound  mercuric  chloride. 

I  pound  manganese  sulphate. 

I  [jound  phenol. 

I  pound  potassium  permanganate. 

I  pound  potassium  iodide. 

5  pounds  potassium  hydroxide. 

I  ounce  potassium  sulphocyanide. 

I  pound  silver  nitrate. 

I  ounce  silver  nitrite. 

I  pound  sodium  thiosulphate. 

I  pound  sodium  carbonate. 

I  pound  sodium  chloride. 

Stains  and  indicators. 

I  ounce  methyl  orange. 

I  ounce  phenolphthalein. 

I  ounce  erythrosine. 

I  ounce  fuchsine. 

I  ounce  methylene  blue. 

I  ounce  Bismarck  brown. 

4  ounces  Wright  differential  blood  stain. 

I  pound  starch  (potato). 

4  ounces  sulphanilic  acid. 

Miscellaneous 

5  grams  No.  i8  platinum  wire. 
I  platinum  evaporating  dish. 

4  Bunsen  burners. 

4  ring  stands. 

5  pounds  rubber  tubing. 
5  pounds  cotton  batting. 


APPENDIX  D  Cll 

6  wire  baskets  for  tiiljcs. 

Assortment  enameled  iron  dishes  and  pans. 

4  special  milk-collecting  baskets  to  order. 

Printed  forms,  etc. 

I  dozen  box  labels. 

Other  small  articles. 

REFERENCES 

Boiling,  "  The  Development  of  a  Municipal  Laboratory,"  Am. 
Jour.  Pub.  Health,  1912,  vol.  ii,  no.  6,  p.  409. 

Standard  Methods  of  the  American  Public  Health  Association  for 
the  examination  of  milk,  air,  water  and  sewage.  These  methods 
should  be  exactly  observed  by  public  health  laboratories.  (Apply  to 
Am.  Jour.  Pub.  Health,  755  Boylston  St.,  Boston,  Mass.:  "Bacterial 
Examination  of  Milk  and  Air,"  25  cents;  "Examination  of  Water  and 
Sewage,  physical,  chemical,  microscopical  and  bacteriological,"  $1.25, 
postpaid.)  Amendments  are  made  by  committee  reports  of  the  Labora- 
tory Section  of  the  Association  from  time  to  time. 

No  attempt  can  be  made  here  to  give  a  complete  bibliography  of 
the  various  works  on  the  different  phases  of  laboratory  work.  The 
following  are  among  the  more  important: 

Jordan,  "  A  Text-Book  of  General  Bacteriology,"  W.  B.  Saunders, 
Phila.,  1914. 

Park  and  Williams,  "Pathogenic  Micro-Organisms;  including  Bac- 
teria and  Protozoa,"  Lea  Bros,  and  Co.,  Phila.,  1910. 

MacNeal,  "Pathogenic  Micro-Organisms"  (based  on  Williams's 
"Manual  of  Bacteriology"),  P.  Blakiston  Son  and  Co.,  Phila.,  1914. 

Prescott  and  Winslow,  "  Elements  of  Water  Bacteriology,"  John 
Wiley  and  Sons,  Inc.,  N.  Y.,  1914. 

Rosenau,  "  Preventive  Medicine  and  Hj'giene,"  Appleton  and  Co., 
N.  Y.,  1913,  sees.  HI  (Foods),  IV  (Air)  and  VI  (Water). 

Woodman  and  Norton,  "  Air,  Water,  and  Food  "  (composition  and 
physical  and  chemical  tests),  John  Wiley  and  Sons,  Inc.,  N.  Y.,  1914. 

Farrington  and  Woll,  "Testing  Milk  and  Its  Products,"  Mendata 
Book  Co.,  Madison,  Wis.,  1912. 

Bull.  100,  Bureau  of  Chemistry,  U.  S.  Dept.  of  Agriculture,  "  Some 
Forms  of  Food  Adulteration  and  Simple  Methods  for  Their  Detection." 

The  more  exhaustive  treatises  on  water,  foods,  milk,  etc.,  may  also  be 
consulted. 


APPENDIX    E 

RULES  OF  STATISTICAL  PRACTICE 

(Adopted  by  the  American  Public  Health  Association  and  by  the 
Bureau  of  the  Census.)^ 

RULES  ADOPTED   IN    1908 

STATEMENT   OF   OCCUPATION 

1.  An  attempt  should  be  made  to  secure  not  only  the  kind  of  occupa- 
tion (e.g.,  laborer),  but  also  the  kind  of  industry  (e.g.,  pottery). 

2.  Occupations  should  be  stated  for  all  decedents  over  10  years  of 
age  (and  for  decedents  under  10  years  of  age  if  employed  in  a  mill, 
factory'  or  in  any  gainful  occupation). 

STATISTICAL   DEFINITION   OF   DEATHS 

3.^  Total  deaths,  as  stated  in  mortality  reports  and  bulletins,  should 
include  all  deaths  that  occurred  in  the  area  of  the  state  or  city  during 
the  specified  time. 

'  1908,  1909  and  191  o  Rules  from  U.  S.  Census  Bulletin  108  (Mor- 
tality Statistics,  1909);  1914  rules  not  jet  in  print  at  time  of  writing, 
but  were  furnished  by  courtesy  of  Dr.  Louis  L  Dublin,  Secretary  of 
Section  on  Vital  Statistics,  A.  P.  H.  A. 

^  Referring  to  Rules  3,  li  and  15:  the  present  ruling  (which  was 
adopted  for  reasons  of  expediency)  requiring  inclusion  of  deaths  of  non- 
residents is  unsatisfactory  for  the  reason  that,  if  it  is  strictly  followed, 
communities  having  hospitals  and  other  institutions  located  within 
their  limits  have  their  death  rates  unduly  swelled  by  the  inclusion  of 
the  deaths  of  non-residents  occurring  in  such  institutions.  It  is  there- 
fore necessary,  for  correct  interpretation  of  the  figures,  to  state  such 
deaths  separately,  and  they  should,  in  fact,  be  tabulated  entirely  apart 
throughout  statistical  reports.  Such  tabulations  should,  however,  be 
accompanied  by  a  statement  of  the  general  death  rate  including  all 
deaths  within  the  district  and  a  statement  indicating  exactly  what  rule 
for  exclusions  has  been  followed.  Such  procedure  is  sanctioned  by  the 
following  resolution  adopted  by  the  American  Public  Health  Association 
in  1913: 

"  Pending  the  final  determination  as  to  forms  of  statistical  tables 

612 


APPENDIX  E  C13 

STILLBIRTHS    (AS    KICLATIiD   TO    DKATIIS) 

4.  Stillbirths  should  not  be  included  in  deaths. 

5.  Children  born  alive  and  living  for  any  time  whatever,  no  matter  how 
brief,  after  birth,  should  not  be  classed  as  stillbirths,  even  though  re- 
ported by  the  attending  physicians  or  midwives  as  "  stillborn." 

6.  Whenever  age,  in  days,  hours,  or  minutes,  is  reported  for  a  "  still- 
born "  child,  or  indicated  i)y  a  difference  between  dates  of  birth  and 
death,  the  registrar  should  secure  a  statement  that  will  enable  the  case 
to  be  classed  with  certainty  either  as  a  stillbirth  or  as  a  death.  If  no 
additional  information  can  be  obtained,  the  statement  of  age  should 
govern,  and  the  case  be  compiled  as  a  death,  not  as  a  stillbirth. 

PREMATURE    BIRTHS 

7.  Premature  births  (not  stillborn)  should  be  included  in  total  deaths 
(classified  under  International  Title  No.  151)  [and  in  total  births]. 

8.  Premature  births  (stillborn)  should  be  classed  under  stillbirths, 
and  should  not  be  included  in  total  deaths. 

9.  When  a  premature  birth  is  reported  as  "  stillborn  "  and  an  in- 
consistent statement  of  age  (days,  hours,  minutes)  is  also  given,  the 
registrar  should  endeavor  to  secure  a  statement  that  will  enable  the 
case  to  be  classed  with  certainty  either  as  a  stillbirth  or  as  a  death.  If 
no  additional  information  can  be  obtained,  the  statement  of  age  should 
govern,  and  the  case  be  compiled  as  a  death,  not  as  a  stillbirth. 

10.  When  a  premature  birth  is  reported  with  no  statement  of  age 
(space  left  blank),  the  local  registrar  should  endeavor  to  obtain  a  state- 
ment of  age,  or  at  least  that  the  child  was  born  alive;  but,  in  the  absence 
of  any  further  data,  the  case  should  be  compiled  as  a  stillbirth. 

DEATHS    OF    NON-RESIDENTS 

11.^  All  deaths  of  transients  or  non-residents  occurring  in  a  state  or 
city  should  be  included  in  the  tables  of  total  deaths. 

and  the  adoption  of  definite  rules  of  statistical  practice,  it  is  the  sense 
of  the  Section  on  Vital  Statistics  of  the  A.  P.  H.  A.  that  bulletins  and 
reports  may  contain  (i)  a  statement  of  mortality  including  deaths  of 
all  persons  and  for  all  causes  with  corresponding  death  rates,  and  (2)  a 
statement  of  mortality  based  on  deaths  of  residents  only  with  corre- 
sponding death  rates,  which  should  be  accompanied  with  a  full  expla- 
nation as  to  the  exact  class  of  cases  and  period  of  time  of  residence 
covered  in  the  exclusions." 

It  is  to  be  hoped  that  some  definitive  ruling  will  be  given  in  the  near 
future.  See  also  page  617  (rules  pending)  and  the  discussion  on  page 
507  f.  (note)  of  the  present  volume.  —  Author. 

^  See  preceding  note. 


6 14  A  MANUAL   FOR  HEALTH  OFFICERS 

DEATHS   IN    INSTITUTIONS 

12.  Deaths  of  residents  of  a  city  in  a  hospital  or  institution  situated 
within  the  city  Hmits  should  be  distributed  by  the  local  registrar  to  the 
districts  of  residence  (borough,  ward,  sanitary  district)  as  far  as  possible. 

PERIOD  COVERED  IN  BULLETINS  AND  REPORTS 

13.  Total  deaths  should  include  all  deaths  that  occurred  in  the  given 
area  during  the  period  stated  in  the  table,  and  no  others: 

(a)  A  weekly  bulletin  should  include  all  deaths  that  occurred  during 
the  week  ending  at  12  p.m.,  Saturday,  and  no  others:  Provided,  that 
in  order  to  secure  earlier  publication,  a  weekly  bulletin  may  include 
"  deaths  reported  "  up  to  any  time,  but  should  definitely  state  that  fact. 

{b)  A  monthly  bulletin  should  include  all  deaths  that  occurred  during 
the  calendar  month,  and  no  others.  [Amended,  see  Rule  no.  i,  1910, 
below.] 

(c)  An  annual  report  should  include  all  deaths  that  occurred  during 
the  calendar  year,  and  no  others. 

HEADINGS   OF   TABLES 

14.  Every  table  of  total  deaths  should  explicitly  state  in  its  heading 
that  stillbirths  are  not  included,  and  if  any  classes  of  deaths  are  omitted 
from  a  table  apparently  relating  to  total  deaths,  the  items  excluded 
should  be  explicitly  stated  either  in  the  heading  or  in  a  footnote. 

DEATH  RATES  BASED  ON  TOTAL  DEATHS 

15.1  Any  statement  of  the  death  rate  (general,  crude  or  gross  death 
rate)  of  a  state  or  city  should  be  understood  to  be  based,  unless  expressly 
qualified,  upon  the  total  deaths,  exclusive  of  stillbirths,  and  without  any 
omissions  of  deaths  whatsoever. 

VIABILITY   OR    NONVIABILITV 

16.  Statement  of  viability  or  nonviability  of  an  infant  prematurely 
born  shall  not  be  considered  in  classification. 

STATISTICAL    DEFINITION    OF    STILLBIRTHS 

17.  For  registration  purposes,  stillbirths  should  include  all  children 
born  who  do  not  live  any  time  whatever,  no  matter  how  brief,  after 
birth. 


^  See  note,  p.  612. 


APPENDIX   E  615 

18.  Birth  (completion  of  birth)  is  the  instant  of  com()lete  separation 
of  the  entire  body  (not  body  in  the  restricted  sense  of  trunk,  but  the 
entire  organism,  including  head,  trunk  and  limbs)  of  the  child  from  the 
body  of  the  mother.  The  umi)ilical  cord  need  not  be  cut  or  the  placenta 
detached  in  order  to  constitute  com[)lete  birth  for  registration  purposes. 
A  child  dead  or  dying  a  moment  before  the  instant  of  birth  is  a  stillljirth, 
and  one  dying  a  moment,  no  matter  how  brief,  after  birth,  was  a  living 
child,  and  should  not  be  registered  as  a  stillbirth.  [In  the  latter  case 
both  a  birth  certificate  and  a  death  certificate  should  be  filed.] 

19.  No  child  that  shows  any  evidence  of  life  after  birth  should  be 
registered  as  a  stillbirth. 

20.  Stillbirths  should  not  be  included  in  tables  of  births  or  in  tables 
of  deaths.     They  should  be  given  in  separate  tables  of  stillbirths. 

21.  It  is  not  desirable  that  midwives  be  allowed  to  sign  certificates 
of  stillbirths. 

STATISTICAL   DEFINITION   OF    BIRTHS 

22.  Total  births  should  include  children  born  alive  only,  and  headings 
of  tables  should  state  that  stillbirths  are  excluded. 

23.  Whenever,  under  the  foregoing  rules  a  death  should  be  registered, 
there  should  be  a  corresponding  registration  at  some  previous  time  of  a 
birth;  and  whenever  a  stillbirth  is  registered  it  should  be  rigorously 
excluded  from  both  the  statistics  of  births  and  deaths. 

ESSENTIAL    REQUIREMENTS    FOR   THE    REGISTRATION   OF   DEATHS 

24.  The  deaths  must  be  recorded  immediately  after  their  occurrence. 
Note.  —  In  statistical  practice  the  terms  "  record  "  and  "  recording  " 

should  be  used  in  the  limited  sense  of  receiving  and  filing,  while  the 
term  "  register  "  and  "  registration  "  should  be  used  as  embracing  the 
further  idea  of  inclusion  of  the  records  in  the  statistics  of  the  area. 

25.  Certificates  of  death  of  standard  form  should  be  used. 

26.  Burial  or  removal  permits  are  essential  to  the  enforcement  of  the 
law. 

27.  Efficient  local  registrars  are  necessary. 

28.  The  responsibility  for  reporting  deaths  to  the  local  registrar 
should  be  placed  upon  the  undertaker  or  other  person  having  charge 
of  the  disposition  of  the  body. 

29.  The  central  registration  office  should  have  full  control  of  the 
local  machinery,  and  its  rules  should  have  the  effect  of  law. 

30.  The  transmission  and  preserv^ation  of  returns  should  be  provided 
for. 

31.  Penalties  should  be  provided  and  enforced. 

[Additional  rules  regarding  deaths  adopted  in  1910  (see  below).] 


6l6  A  MANUAL  FOR  HEALTH  OFFICERS 

ESSENTIAL   REQUIREMENTS   FOR   THE    REGISTRATION    OF    BIRTHS 

32.  Births  must  be  recorded  immediately  after  their  occurrence. 

33.  Certificates  of  birth  of  standard  form  should  be  required. 

34.  Some  clieck  is  necessary  to  secure  enforcement  of  the  law. 

35.  Efiicient  local  registrars  are  necessar>'. 

36.  The  responsibility  for  reporting  births  to  the  local  registrar 
should  be  placed  upon  the  attending  physician  or  midwife,  and  upon 
the  parents  if  no  physician  or  midwife  was  in  attendance. 

37.  The  central  registration  office  should  have  full  control  of  the  local 
machinery,  and  its  rules  should  have  the  effect  of  law. 

38.  The  transmission  and  preservation  of  returns  should  be  provided 
for. 

39.  Penalties  should  be  provided  and  enforced. 

METHOD   OF   TESTING   ACCURACY   OF   REGISTRATION   OF   DEATHS 

40.  The  accuracy  (completeness  with  respect  to  total  number)  of  the 
registration  of  deaths  in  a  state  or  city  may  be  satisfactorily  determined 
by  the  proportion  found  actually  registered  out  of  a  sufficiently  large 
number  (10  per  cent  of  the  total  ?)  derived  from  any  independent  source, 
e.g.,  newspaper  reports,  and  properly  distributed  throughout  the  state. 

41.  Local  registrars  should  regularly  note  newspaper  reports  of 
deaths,  in  order  to  detect  omissions  and  secure  complete  registration. 

42.  Registrars  should  periodically  examine  the  records  of  interments 
in  cemeteries  used  by  their  districts  and  check  up  any  interments  made 
without  proper  registration  and  permit,  in  order  to  ascertain  the  num- 
ber of  unregistered  deaths. 

METHOD   OF   TESTING   ACCURACY   OF    REGISTRATION   OF    BIRTHS 

43.  The  accuracy  (completeness  with  respect  to  total  number)  of  the 
registration  of  births  in  a  state  or  city  may  be  satisfactorily  determined 
by  the  proportion  found  actually  registered  out  of  a  sufficiently  large 
number  (10  per  cent  of  the  total  ?)  derived  from  any  independent  source, 
e.g.,  newspaper  reports  or  lists  of  infants  registered  as  births,  and  whose 
certificates  of  death  enable  the  place  and  date  of  birth  to  be  fixed,  pro- 
vided they  are  properly  distributed  throughout  the  state. 

CONSTRUCTION   OF    STANDARD   TABLES   OF   VITAL    STATISTICS 

44.  Every  state  or  city  registration  office  should  publish  an  annual 
(or  biennial)  report  and  include  therein  a  table  showing  the  population 
(as  estimated  by  the  United  States  Census  Bureau  for  intercensal  years), 
total  number  of  births  exclusive  of  stillbirths,  total  number  of  deaths 
exclusive  of  stillbirths,  total  number  of  stillbirths,  total  number  of 
marriages^  and  total  number  of  divorces  '  for  each  year  of  registration. 

^  Provided  this  item  can  be  obtained. 


APPENDIX   E  617 

45.  It  is  desirable  that  the  corresponding  rates  be  given,  but  the 
primary  figures  should  be  presented  whether  it  is  possible  to  jjresent 
rates  or  not. 

46.  Notes  should  be  given  in  all  instances  where  discrepant  figures 
have  been  officially  printed  relative  to  returns  for  any  year,  and  the 
correct  figures  should  be  definitely  stated. 

47.  Notes  should  be_givcn  on  changes  in  methods  of  compiling  still- 
births, and  a  correct  statement  of  stillbirths  should  be  established  for 
each  year,  on  the  basis  of  the  definitions  approved.  If  necessary,  re- 
examination of  the  original  return  should  be  made  for  the  purpose  of 
obtaining  comparable  figures. 

ADOPTION   OF   UNIFORM   AGE    PERIODS   IN   MORTALITY   STATISTICS 

48.  Unknown  ages  should  never  be  accepted  in  returns.  The  approx- 
imate age,  according  to  the  best  judgment  of  the  reporter,  should  be 
given  if  the  exact  age  is  unknown.  When  accepted  by  the  central 
registration  ofifice,  however,  they  should  be  given  a  place  in  the  state- 
ment of  ages,  in  order  to  show  the  imperfect  quality  of  registration. 

RULES   ADOPTED   IN    1909 

Revised  United  States  Standard  Certificate  of  Death 

[The  five  rules  adopted  in  1909  (with  Rule  no.  2  of  1910)  provide  for 
a  uniform  mode  of  statement  of  causes  of  death  upon  certificates  of 
death,  the  need  of  efforts  to  obtain  more  definite  and  satisfactory  state- 
ment of  causes  of  death,  and  prescribing  the  adoption  of  the  Revised 
United  States  Standard  Certificate  of  Death  (or  at  least  of  the  standard 
form  of  statement  of  cause  of  death  and  occupation)  with  the  minimum 
instructions  printed  on  the  reverse  thereof.^  It  is  also  advised  that 
instructions  in  regard  to  reporting  of  occupations  be  uniform  in  popula- 
tion, industrial  and  mortality  schedules  (certificates  of  death).] 

RULES  ADOPTED   IN    1910 

I.  [APHA]  Rule  no.  13  of  1908,  paragraph  (b),  shall  be  amended  to 
read  as  follows: 

"  (b)  A  monthly  bulletin  should  include  all  deaths  that  occur  during 
the  calendar  month  and  no  others,  provided,  however,  that  in  order 
to  secure  earlier  publication,  a  monthly  bulletin  may  include  '  deaths 
reported  '  during  the  calendar  month,  but  should  definitely  state  that 
fact." 

^  Copies  of  the  certificate  may  be  obtained  on  application  to  the 
Division  of  Vital  Statistics,  Bureau  of  the  Census. 


6i8  A  MANUAL  FOR  HEALTH  OFFICERS 

2.  .The  instructions  as  printed  upon  the  reverse  side  of  the  Revised 
Standard  Certificate  of  Death  in  regard  to  the  reporting  of  occupation 
shall  be  the  minimum  instructions  employed  for  this  purpose,  and 
shall  be  enforced  as  provided  for  by  [APHA]  Rule  no.  3  of  1909  [i.e.,  by 
state  registration  offices]. 

3.  Passengers  dying  on  trains  or  vessels  should  be  registered  as 
deaths  at  the  station  or  port  where  the  bodies  are  removed. 

4.  Deaths  caused  by  railroad  accidents  or  by  disasters  incident  to 
navigation  should  be  registered  in  the  district  that  includes  the  place 
of  death,  or  where  the  bodies  were  brought  ashore. 

5.  [Provides  for  a  modified  form  of  the  Standard  Certificate  of  Death 
for  the  use  of  coroners  (or  medical  examiners)  where  such  special  forms 
are  deemed  necessary.] 

RULES  ADOPTED    IN    1914 

1.  It  is  desirable  that  all  stillbirths,  irrespective  of  the  month  of 
uterogestation,  be  registered. 

2.  A  table  of  stillbirths  should  be  given  which  will  show  the  number 
registered  at  each  completed  month  of  uterogestation,  together  with 
the  number  for  which  no  statement  of  the  duration  of  uterogestation 
was  given. 

3.  For  comparative  statistical  purposes  the  main  tables  of  stillbirths 
should  include  only  those  stillbirths  which  have  attained  the  age  of 
six  (6)  completed  months  of  uterogestation,  or,  in  other  words,  have 
advanced  to  the  seventh  (7th)  month  of  uterogestation  or  were  born 
after  the  sixth  (6th)  month  of  uterogestation.  Such  tables  should  state 
explicitly  that  they  exclude  certain  stillbirths  that  were  or  might  be 
registered:  "  Stillbirths  (exclusive  of  those  stated  as  less  than  six  months 
of  uterogestation)." 

[No  rules  were  adopted  in  191 1,  1912  or  1913.  Rules  are  still  pend- 
ing which  propose:  (i)  that  separate  columns  for  deaths  of  non- 
residents may  be  given  including  deaths  in  hospitals  and  institutions 
and  of  transients  and  non-residents  at  place  of  death  less  than  6  (?) 
months  and  less  than  the  duration  of  the  disease  causing  death;  (2) 
that  deaths  of  residents  occurring  in  institutions  (e.g.,  almshouses) 
situated  outside  of  a  city  but  which  draw  inmates  therefrom  be  included 
in  the  statistics  of  the  city;  and  (3)  that  deaths  in  state  or  government 
institutions  be  included  in  the  statistics  of  the  areas  containing  them, 
but  that  special  columns  may  be  employed  to  permit  separate  statement 
as  in  case  of  non-residents.] 


APPENDIX    F 

COOPERATIVE    HEALTH    ADMINISTRATION 
AMONG    SMALL    COMMUNITIES 

There  is  today  in  the  pubHc  health  field  no  more  vital  problem  than 
how  small  towns  and  cities  can,  with  their  limited  resources,  obtain  the 
expert  service  which  they  require.  This  pressing  problem  has  already 
been  discussed  in  Part  I,  Chapters  I  and  II,  in  which  two  possible  solu- 
tions were  outlined.  One  of  these  is  the  New  York  State  plan,  by 
which  a  greater  degree  of  supervision  of  state  over  local  authorities  is 
established,  —  a  plan  which  at  the  present  time  (1914),  while  holding 
out  great  promise,  is  still  in  the  inceptive  stage.  The  other  plan  is  that 
of  cooperative  maintenance  of  a  joint  health  office  by  two  or  more  neighbor- 
ing communities.  Fortunately  there  are  already  available  data  on  the 
successful  outcome  of  an  experiment  —  the  first  noteworthy  one  of  its 
kind  —  illustrating  the  joint  plan  as  it  has  been  worked  out  in  a  certain 
group  of  Massachusetts  towns.  The  results  are  set  forth  at  length  in 
a  recent  paper  by  Earle  B.  Phelps,  summarized  as  follows: 

The  local  health  oiifice  in  the  smaller  communities  is  the  most 
essential  and  least  efficient  part  of  the  present-day  public  health 
machine.  The  highly  specialized  character  of  public  health  work 
and  the  financial  inability  of  the  smaller  community  to  support  a 
properly  trained  health  organization  are  in  large  measure  respon- 
sible for  this  condition. 

Consolidation  of  adjoining  communities  in  a  cooperative  health 
office  will  provide  a  sufficient  population  to  support  the  requisite 
minimum  organization  for  efficient  health  work  at  a  per  capita 
charge  much  less  than  that  usually  imposed  in  the  larger  cities  for 
work  of  a  similar  character. 

• 

The  Cooperative  Plan 

f 
The  details  of  such  a  cooperative  effort  inaugurated  among  cer- 
tain  Mr.ssachusetts  towns  by  the  officers  of  the  department  of 
biology  and  public  health  of  the  Massachusetts  Institute  of  Tech- 
nology are  given. 

This  work  was  assisted  by  the  Surgeon  General  of  the  United 
619 


620  A  MANUAL  FOR  HEALTH  OFFICERS 

States  Public  Health  Service  through  the  detail  of  a  sanitary 
bacteriologist  and  through  the  devoting  of  a  portion  of  the  writer's 
time  to  the  general  supervision  of  the  work  since  October  i,  1913. 

An  organization  comprising  an  administrative  officer,  a  bacte- 
riologist and  secretary,  a  siinitary  and  plumbing  inspector,  a  field 
assistant,  and  two  clerks  served  a  population  of  32,650  in  all  de- 
partments of  the  work  except  plumbing  inspection  (a  population 
of  8385  being  served)  and  an  additional  population  of  30,000  in 
milk  inspection  and  control,  at  a  cost  of  $7603.51  for  the  year. 

The  output  of  such  a  health  office  can  be  increased  by  the  appoint- 
ment of  assistance  at  less  than  a  proportionate  increase  in  main- 
tenance costs. 

Results 

The  prompt  measures  taken  in  the  preliminary  investigation  of 
every  case  of  contagious  disease,  backed  up  by  the  findings  of  the 
diagnostic  laboratory,  have,  in  at  least  two  cases,  prevented  serious 
outbreaks  of  contagious  disease  and  would  undoubtedly  have  pre- 
vented a  third  outbreak  and  one  death  had  they  been  in  force  In  a 
neighboring  town  from  which  a  carrier  case  was  imported. 

The  average  bacterial  content  of  the  milk  supply  has  been  re- 
duced by  approximately  two-thirds  without  any  restrictive  meas- 
ures having  been  imposed  upon  the  producers  themselves  other 
than  those  already  in  force.  This  has  been  done  by  a  systematic 
laboratory  control  of  the  milk  supply  embodying  monthly  chemical 
and  bacterial  analyses,  by  a  policy  of  publicity,  and  by  helpful, 
constructive  criticism  given  to  the  producers  upon  request.  The 
improvement  is  of  especial  significance  in  view  of  the  generally 
good  quality  of  the  milk  supplies  in  question.  Starting  with  32  per 
cent  of  the  individual  supplies  below  10,000  bacteria  per  cubic 
centimeter  and  50  per  cent  below  20,000,  one  year  later  31  per  cent 
were  below  5000,  56  per  cent  below  10,000,  and  74  per  cent  below 
20,000. 

Prompt  and  energetic  measures  were  adopted  in  the  control  of 
contagious  diseases,  every  efTort  being  made  to  locate  the  initial 
source. 

Campaigns  for  mosquito  and  fly  suppression  were  carried  through 
successfully. 

Costs 

An  accounting  system,  showing  full  details  of  the  costs  of  this 
work,  was  employed.  The  work  of  the  diagnostic  laboratory  and 
the  milk  inspection  and  control  cost  approximately  3  cents  per 
capita  per  annum  each,  and  the  work  of  sanitary  Inspection  and 


MM'I'INDIX    F  621 

control  of  conlaKious  disease  cost  sli^I'lly  more.  The;  total  cost 
of  the  work,  exclusive  of  [)liimi)inf;  ins|)Cctiori,  was  i<)  cents  per 
capita  per  annum. 

A  population  of  about  60,000  would  flevelop  each  of  the  various 
subdivisions  of  the  work  to  a  point  of  maximum  efficiency  and 
could  support  the  work  of  a  complete  organization,  inclurling  two 
district  nurses  and  medical  and  veterinary  advisory  services,  at  a 
per  capita  cost  (exclusive  of  plumbing  inspection)  of  one-half  the 
average  cost  of  board  of  health  work  in  the  large  cities  of  the 
United  States. 

Organization 

Such  a  cooperative  office  may  be  organized  among  the  towns 
themselves,  through  the  initiative  of  State  or  educational  authori- 
ties, or  under  the  direction  of  a  consulting  sanitarian,  or  it  may  be 
conducted  entirely  by  an  outside  consulting  office  specializing  in 
public  health  work. 
The  equipment  and  duties  of  a  local  health  office,  the  problems  of 
local  administration  and  the  minimum  requirements  of  such  an  office 
are  discussed  at  some  length,  and  the  year's  work  under  a  permanent 
organization  is  reported  upon  in  detail,  with  analysis  of  costs.     Appen- 
dices giving  the  form  of  agreement  adopted  and  a  list  of  the  necessary 
laboratory  equipment  for  a  small  board  of  health  laboratory  (see  Appen- 
dix D  of  present  volume)  are  added. 

Such  a  cooperative  plan,  it  may  be  added,  does  not  necessarily  imply 
the  consolidation  of  town  interests  in  any  other  respect  than  that  of 
public  health,  or  even  complete  consolidation  in  that. 

This  important  paper  is  printed  in  Public  Health  Reports  for  Septem- 
ber 25,  1914  (copies  of  which  may  be  obtained  from  the  U.  S.  Public 
Health  Service,  Washington),  and  should  be  carefully  read  by  all  health 
officers  for  its  analysis  of  needs  and  methods  as  well  as  for  its  account 
of  the  cooperative  plan. 


APPENDIX    G 

STANDARD    PLAN    FOR    ANNUAL    REPORTS  ^ 

FOREWORD 

This  report  is  a  schematic  outline,  more  or  less  detailed,  for  annual 
reports  of  municipal  boards  of  health.  By  expansion  or  contraction, 
the  outline  submitted  may  be  applied  to  cities  of  any  size.  As  it  deals 
only  with  fundamentals,  its  adoption  need  not  prevent  originality  of 
treatment. 

GENERAL   OUTLINE 

I.  Title  Page. 

II.  Members  of  Board  and  Staff. 

III.  Table  of  Contents. 

IV.  Summary  of  the  Year's  Work. 
V.  Report  of  the  Executive  Officer. 

1.  Introduction. 

2.  Vital  Statistics. 

3.  Communicable  Diseases. 

4.  Infant  Welfare. 

5.  Medical  Inspection  of  Schools. 

6.  Foods  and  Drugs. 

7.  Water  and  Ice  Supply. 

8.  Sanitary  Inspection  of  Buildings. 

9.  Nuisances. 

10.  Municipal  Wastes. 

11.  Plumbing. 

12.  Insects  and  Rodents. 

13.  Special  Problems  and  Research. 

14.  Publicity. 

15.  New  Ordinances. 

16.  Prosecutions. 

17.  Conclusion  and  Recommendations. 
VI.    Financial  Statement. 

^  Health  Officers' Association  of  New  Jersey,  1913.  The  plan  adopted 
by  the  Mass.  Assn.  of  Boards  of  Health,  which  is  closely  comparable  with 
the  above,  has  already  been  published  in  the  Am.  Jour.  Pub.  Health 
(1913,  vol.  Ill,  no.  6,  p.  595).  The  Massachusetts  plan  embraces:  a 
form  for  a  report  suitable  for  cities  of  30,000  inhabitants  and  over,  a 
form  for  smaller  places,  explanatory  notes  and  forms  for  tables. 

622 


APPENDIX   G  623 

When  no  work  has  been  done  alon^^  any  line  indicatcfl  in  the  general 
outline,  statisLics  should  be  jiresenLed  to  demonstrate  existin^^  needs; 
or,  if  the  work  has  been  done  l)y  another  nuinicijjal  dejjartment  or  by 
a  private  organization,  that  fact  should  be  nested.  Special  endeavor 
should  be  made  to  interpret  concisely  all  taliulated  statistics.  In  the 
following  outlines,  capital  letters  in  brackets  indicate  tables. 

REPORT    OF   THE   EXECUTIVE   OFFICER 

Section  i,  Introduction 

Section  2,  Vital  Statistics 

Comment  should  be  made  on  existing  laws,  methods  of  enforcement 
and  need  for  further  legislation. 

I.    POPULATION 

(A)  POPULATION  as  of  July  i  for  the  year  and  for  each  of  the  ten 

years  preceding.  Estimates  should  be  made  according  to  the 
method  of  the  U.  S.  Census  Bureau.  (Reference  no.  i  at  the 
end  of  the  report.) 

(B)  POPULATION,  for  the  current  year  at  least,  tabulated  by  (i) 

wards,  (2)  age  periods,  (3)  color  and  (4)  principal  nationalities. 

II.   BIRTHS 

Children  born  to  non-resident  mothers  in  hospitals  should  be  tabu- 
lated separately.  Stillbirths  should  be  tabulated  separately,  not  with 
births  or  deaths. 

(A)  BIRTH  RATES  per  thousand  of  population  for  the  year  and 

for  each  of  the  ten  years  preceding. 

(B)  BIRTH  RATES,  for  the  current  year  at  least,  by  (i)  wards, 

(2)  color  and  (3)  principal  nationalities. 

(C)  NUMBER  OF  BIRTHS  tabulated  by  (i)  wards,  (2)  color,  (3) 

principal  nationalities,  (4)  sex,  (5)  number  of  child,  (6)  plural 
births,  (7)  legitimacy,  (8)  number  attended  by  midwives  and 
(9)  completeness  of  the  certificates  as  to  the  given  name  of  the 
child. 

III.  DEATHS 

Deaths  should  be  classified  according  to  the  international  s\'stem. 
(Reference  no.  2.)  Deaths  of  non-residents  in  hospitals  should  be  tab- 
ulated separately. 

(A)  DEATH  RATES  per  thousand  of  population  for  the  year  and 
for  each  of  the  ten  years  preceding  by  (i)  wards,  (2)  color 
and  (3)  principal  nationalities. 


624  A  MANUAL   FOR  HEALTH  OFFICERS 

(B)  DEATH  RATES  per  hundred  thousand  of  population  for  deaths 

during  the  current  year  due  to  communicable  diseases  and 
principal  causes. 

(C)  NUMBER  OF   DEATHS  during   the  year  tabulated  by    (i) 

wards,     (2)    color,     (3)    principal    nationalities    and     (4)  age 
periods. 
Each  cause  for  which  there  was  an  unusual  number  of  deaths  should 
be  discussed  in  detail. 

IV.   MARRIAGES 

(A)  MARRIAGE  RATE  per  thousand  of  population. 

(B)  NUMBER  OF  MARRIAGES  classified  according  to  (i)  resi- 

dence, (2)  color  and  (3)  principal  nationalities. 
Give  the  name  and  title  of  the  person  issuing  marriage  license  and 
any  other  necessary  information  relating  thereto. 

Section  3,  Commtuiicable  Diseases 

Distinguished  as  to  residence  of  the  cases  and  place  where  disease  was 
contracted;  i.e.,  separate  locally  contracted  cases  of  residents,  cases  of 
residents  contracted  out  of  town  and  imported  cases  of  non-residents. 
Exclude  from  local  statistics  cases  of  non-residents  treated  in  local 
hospitals  and  include,  so  far  as  possible,  cases  of  residents  treated  at 
out-of-town  hospitals.  State  the  method  of  disinfection  used  (give 
names  and  quantities  of  materials)  and  show  for  what  diseases  employed. 

(A)  CASES  AND  DEATHS  for  each  of  the  communicable  diseases 

for  the  year  and  for  each  of  the  ten  years  preceding. 

(B)  DEATH  RATES  per  hundred  thousand  population  for  the  year 

for  each  of  the  chief  communicable  diseases. 

(C)  DEATHS    FROM    PRINCIPAL    COMMUNICABLE    DIS- 

EASES tabulated  by  (i)  wards  and  (2)  months. 

(D)  CASE  MORTALITY  for  each  of  the  chief  communicable  dis- 

eases. 

Discuss  prevalence,  methods  of  control,  possible  sources  of  infection, 
use  of  laboratory  diagnosis,  average  length  of  isolation,  and  methods  of 
determining  time  of  release  for  each  of  the  communicable  diseases. 

For  diphtheria,  tabulate  length  of  isolation  by  five-day  periods  and 
for  scarlet  fever,  by  weeks,  separating  home  and  hospital  cases.  Indi- 
cate, also,  extent  of  hospital  treatment  and  numbers  of  multiple  and 
return  cases.  A  statement  as  to  the  use  of  antitoxin  should  be  made 
under  the  heading  of  diphtheria,  giving  number  of  cases  where  used, 
result  on  mortality  and  extent  of  free  distribution  to  indigent  persons. 

Distinguish  between  "  pulmonary  "  and  "  other  forms  "  of  tubercu- 


APPENDIX  G  625 

losis.     If  anti-Lubcrculosis  work  is  carried  on  by  private  agencies,  an 
ouUine  of  its  extent  and  character  should  be  given. 

Under  the  heading  smallpox,  give  (i)  the  vaccinal  status  of  all  cases, 
(2)  of  all  school  children  and  (3)  the  extent  of  free  vaccination. 

Section  4,  Infant  Welfare 

Conditions  affecting  infant  welfare  and  all  agencies  and  means  for 
reducing  infant  mortality  should  be  discussed. 

(A)  NUMBER  OP'  DEATHS  during  the  year  and  each  of  the  ten 

years  preceding,  (i)  under  five  years  of  age,  (2)  under  one 
year  and  (3)  percentage  of  total  deaths  for  each  of  these  age 
groups. 

(B)  RATE  OF  DEATHS  UNDER  FIVE  YEARS  PER  THOU- 

SAND OF  POPULATION  UNDER  FIVE  YEARS  by  (i) 
wards,  (2)  color  and  (3)  principal  nationalities. 

(C)  DEATHS  UNDER  FIVE  YEARS  OF  AGE  tabulated  by  (i) 

days,  for  the  first  week,  (2)  weeks,  for  the  first  month,  (3) 
months,  for  the  first  year  and  (4)  by  years  for  the  first  five 
years,  showing  (a)  chief  causes  of  death,  (b)  color  and  (c) 
nativities  of  parents. 

(D)  DEATHS  FROM  DIARRHOEA  AND  ENTERITIS  UNDER 

TWO  YEARS  OF  AGE  (title  104  of  the  International  Classi- 
fication) and  rate  per  hundred  thousand  of  population  for  the 
year  and  for  each  of  the  ten  years  preceding. 

(E)  RATE  OF  DEATHS  UNDER  ONE  YEAR  OF  AGE  PER 

THOUSAND  BIRTHS  for  the  year  and  for  each  of  the  ten 
years  preceding,  tabulated  by  (i)  wards  or  districts,  (2)  color, 
(3)  nationalities,  (4)  hospital  or  institutional  care  and  (5) 
seasonal  distribution. 

Section  5,  Medical  Inspection  of  Schools 

Public  and  private  schools  should  be  reported  separately.  Separate 
reports  for  general,  dental,  eye  and  other  kinds  of  examinations,  to 
include  the  work  of  examining  physicians,  of  the  school  nurse  and  of 
free  clinics.  State  whether  school  or  calendar  year  is  covered  and  report 
for  the  last  complete  year. 

Section  6,  Foods  and  Drugs 

An  outline  of  the  food  control  problem  and  its  sanitary'  significance  is 
necessary  to  a  proper  appreciation  of  the  work  of  this  department. 
Endeavor  to  make  all  information,  especially  such  as  relates  to  the 
standing  of  the  various  milk  supplies,  comprehensible  and  useful  to 
the  public.     Technical  terms  should  be  explained  or  avoided.     The  dairy 


626  A  MANUAL   FOR  HE.\LTH  OFFICERS 

score  card  devised  by  the  U.  S.  Department  of  Agriculture  is  recom- 
mended. Any  deviation  from  the  laboratory  methods  of  the  American 
Public  Health  Association  should  be  mentioned  and  explained.  The 
methods  described  in  the  report  of  the  Committee  on  Milk  Standards 
are  recommended.  (Reference  no.  3.)  Explain  system  of  dairy  and 
creamer^'  inspection. 

(A)  GENERAL  AVERAGE  OF  DAIRY  SCORES  for  each  of  the 

preceding  five  or  more  years. 

(B)  NUMBER  (OR  PER  CENT)  OF  DAIRIES  WHOSE  SCORES 

FELL  BETWEEN  CERTAIN  LIMITS  for  above  years. 

(C)  TABLE  OF  ALL  RETAIL  DEALERS  giving  scores  of  dairies 

supplying  each.^  State  whether  milk  dealers  are  licensed  by 
the  Board  and  give  the  number  of  milk  supplies  excluded  with 
reasons. 

Indicate  the  method  and  frequency  of  taking  samples  of 
milk  and  cream  for  analysis. 

(D)  GENERAL  AVERAGE  BACTERIA  COUNT  (OR  BAC- 

TERIAL CONTENT,  Reference  no.  3)  for  each  of  the  pre- 
ceding five  or  more  years. 

(E)  INDIVIDUAL  AVERAGE  (OR  "  BACTERIAL  CONTENT  ") 

for  each  dealer  for  the  year.^ 

(F)  MONTHS  DURING  WHICH  EACH  DEALER'S  BACTERIA 

COUNT  FELL  WITHIN  CERTAIN  LIMITS. 

(G)  Where  "  loose  "  milk  is  sold,  contrast  the  bacteria  counts  of 

bottled  and  loose  milk. 
(H)  BACTERIA    COUNTS.     Results    of    each    analysis    for    each 

dealer. 
(I)    FAT  AND  TOTAL  SOLIDS.     Figures  for  percentage  fat  and 
total  solids  may  be  given  correspondingly  with  bacteria  counts 
in  (D),  (E)  and  (H)  above  and  may  be  conveniently  included 
in  tables  with  the  latter. 
Microscopic  examinations  and  tests  for  sediments,  preservatives  and 
thickeners  should  be  recorded  if  made. 

Give  results  of  inspection  and  measures  to  protect  each  kind  of  food, 
both  during  preparation  (at  slaughterhouses,  bakeries,  ice  cream  fac- 
tories, etc.),  and  during  sale  (at  restaurants,  markets,  etc.).     Report 

1  It  scarcely  need  be  said  that  these  scores  should  be  up  to  date  at 
time  of  report,  and  that  dealers  should  have  been  given  a  reasonable 
time  to  make  improvements  before  scores  are  published  by  name.  — 
J.  S.  M. 

*  Bacteria  tests  must  be  sufficiently  numerous  to  give  a  fair  average 
for  each  dealer.  — J.  S.  M. 


APPENDIX   G  627 

on  the  adulteration  and  misbranding  of  foods  and  drugs  and  tlu;  sale 
of  habit-forniin^^  (lrii^;s,  if  subjects  for  local  action. 

Section  7,  Water  and  Ice  Supplies 

Sources,  c[ualily  and  treatment  of  tlie  various  jjulilic  and  private 
water  supplies;  results  of  analyses  and  inspections.  Similar  data  for 
ice  supplies. 

Section  8,  Sanitary  Inspection  of  Buildings 

Results  of  inspections  of  schools,  tenements,  lodging  houses,  hotels, 
factories  and  other  buildings. 

Section  9,  Nuisances 

Classify  and  tabulate  complaints  received  during  the  year  as  to  (i) 
nature  of  complaint  and  (2)  abatement.  House-to-house  inspections, 
control  of  special  nuisances:  (i)  disposal  of  excreta,  (2)  dead  animals, 
(3)  smoke,  (4)  foul  odors,  (5)  poisonous  gases,  (6)  noise,  etc. 

Section  10,  Municipal  Wastes 
Describe  the  system  of  collection  and  disposal  of  (i)  garbage  and 
olTal,  (2)  ashes. and  non-combustible  waste  and  (3)  combustible  waste, 
considering  each  separately  under  the  following  heads:  (a)  methods 
(by  whom,  for  combined  or  separate,  frequency),  (b)  amounts  (in  cubic 
yards  or  tons),  (c)  costs  and  (d)  nuisances  and  complaints  arising  from 
methods  of  collection  and  disposal. 

Section  11,  Plumbing 

(A)  Permits  of  each  class  for  the  year  and  for  each  of  the  five  j-ears 

preceding. 

(B)  Permits  granted  during  the  current  year  in  (i)   old  and  (2)   new 

buildings,  by  wards. 

(C)  Tabulation  of  preliminary  tests,  final  tests  and  inspections  passed 

and  not  passed,  during  the  year. 

(D)  Sewer  connections.     Number  of  permits  and  inspections. 

(E)  Give  number  of  dwellings  not  connected  with  the  sewer  on  (i) 

sewered  streets,  and  (2)   unsewered  streets. 

(F)  Permits  and  tests  for  gas  piping  and  fixtures. 

Section  12,  Insects  and  Rodents 
Relation  to  public  health,  location  of  breeding  places  and  measures 
of  extermination. 

Section  13,  Special  Problems  and  Research 

Epidemiology  and  etiology  of  communicable  diseases;  improvements 
in  administrative  and  laboratory  methods. 


628  A  MANUAL  FOR  HEALTH  OFFICERS 

Section  14,  Publicity 

Bulletins,  exhibits,  lectures,  instruction  in  sanitation  in  the  public 
schools,  books  on  sanitation  in  the  public  library. 

Section  15,  New  Ordinances 
Give  sections  of  special  importance  in  full,  others  in  abstract. 

Section  16,  Prosecutions 

Causes,  results,  courts  where  prosecuted  and  amount  of  penalties  col- 
lected. 

Section  17,  Conclusions  and  Recommendations 

FINANCIAL  STATEMENT 

Use  the  outline  given  in  reference  no.  4.  Include  statement  of  bills 
outstanding  and  receivable  and  statement  of  supplies  on  hand  at  the 
beginning  and  close  of  fiscal  year. 

REFERENCES 

No.  I.    Bulletins  no.  108  (pp.  8  and  9)  and  109  (p.  9),  Bureau  of  the 

Census. 
No.  2.    International  Classification  of  Causes  of  Sickness  and  Death, 

Bureau  of  the  Census. 
No.  3.    Reprint  no.  78  from  Public  Health  Reports,  U.  S.  Public  Health 

Service. 
No.  4.    Uniform  Accounts  as  a  Basis  for  Standard  Forms  for  Reports 

of  Financial  and  Other  Statistics  for  the  Health  Department, 

by  L.  C.  Powers,  Bureau  of  the  Census. 
[It  will  be  noted  that  in  the  above  plan  the  details  of  laboratory  work 
are  distributed  under  the  various  heads. 

For  details  of  vital  statistics  consult  Chapter  IX,  of  present  volume.] 


APPENDIX    H 
HEALTH    OFFICE    FORMS 

The  following  is  a  suggestive  list  of  health  office  forms  intended  to 
represent  the  minimum  requirements  of  the  health  department  of  a 
small  city.  It  should  naturally  be  modified  to  suit  local  requirements, 
for  it  is  obvious  that  some  departments  would  require  forms  which  do 
not  appear  in  the  list,  while  others  would  perhaps  employ  procedures 
to  which  certain  of  the  forms  suggested  are  not  applicable.  In  most 
cases  printed  forms  are  requisite. 

GENERAL 

Inspector's  daily  (or  weekly)  report  blank.  (Loose-leaf  notebook 
advisable  for  daily  records.)  Daily  record  should  account  in  detail  for 
use  of  time. 

COMMUNICABLE   DISEASE 

Physicians'  (postal)  report  card  for  new  cases,  also  for  recoveries  and 
deaths  (two  forms  on  same  card). 

History  cards  for  diphtheria,  scarlet  fever,  typhoid  fever,  etc. 

Placards. 

Instructions  regarding  isolation  and  disinfection. 

Book  record  for  communicable  diseases. 

Spot  map  of  cases. 

Permit  to  attend  school,  business,  etc. 

Physicians'  application  and  receipt  for  diphtheria  antitoxin  or  other 
serum  (indigent  cases). 

Forms  to  accompany  bacteriological  specimens  (diphtheria,  etc.) 
(name,  address,  etc.). 

Laboratory  book  record  of  examinations. 

Tuberculosis: ' 

Physicians'  special  report  blank  for  new  cases  (sealed  envelope  — 
health  departments  should  furnish  self-addressed  en\-elopes). 

Physicians'  special  report  blank  for  removals  and  deaths  (sealed 
envelope) . 

1  Records  of  tuberculosis  to  be  kept  separate  and  distinct  from  those 
of  other  communicable  diseases. 

629 


630  A  MANUAL   FOR   HEALTH   OFFICPLRS 

History  card  (with  blanks  or  extra  card  for  recording  visits  of  nurse). 

Special  book  record. 

Form  to  accompany  sputum  specimens. 

Instructions  for  tuberculosis  patients. 

Requisition  form  for  sputum  cups,  etc. 

(Clinic  records.) 

Spot  map  of  cases  and  deaths  (not  public). 

(The  law  usually  prescribes  that  tuberculosis  records  be  kept  private.) 

CHILD   HYGIENE 

Histor>'  card  for  each  case,  giving  essential  data,  records  of  nurse's 
visits,  consultation  station  (or  clinic),  examinations,  weights,  diets,  etc. 
Monthly  summary  of  work  of  nurse. 
Monthly  summary  of  work  of  consultation  station. 
Cards  for  clinic  appointments  (language  of  mother). 
Instructions  for  care  of  baby,  diets,  etc. 
Physicians'  report  card  for  cases  of  enteritis. 

MILK   SUPPLIES 

License  and  permit  forms.  Application  form  for  license  (sources  of 
supply,  etc.). 

Score  or  inspection  forms  for  dairies,  creameries,  bottling  plants. 

Laboratory  records  for  recording  results  of  analysis  and  notifying 
dealers. 

OTHER   FOOD   SUPPLIES 

Score  or  inspection  forms  and  forms  of  notification  for  bakeries,  con- 
fectioneries, ice-cream  factories,  places  where  beverages  are  dispensed, 
restaurants  and  the  like. 

WATER 

Forms  for  recording  inspections  of  wells,  etc.,  and  analyses,  so  far  as 
required. 

HOUSING 

House-to-house  inspection  forms. 

Summary  reports  on  house-to-house  inspection  (by  streets),  with 
objectionable  conditions  found. 

Gas  inspection: —  forms  for  new  installations  similar  to  those  used 
for  plumbing  inspection;  forms  for  recording  inspections  of  old  systems, 
tags  for  leaky  fixtures  and  notification  forms. 

Plumbing  inspection:^    (i)  bond  and  registration  forms;    (2)   plan  of 

^  Plumbing  inspection  should  be  removed  from  the  health  depart- 
ment and  assigned  (where  this  is  not  already  the  case)  to  some  other 
and  appropriate  department,  such  as  that  of  building  inspection. 


ai')m;ni)IX  h  631 

proposed  work;  (3)  pcriniL  placard  to  proceed  willi  work;  (4)  inspec- 
tion cerlificatcs  for  roughing  and  water  ((;r  smoke)  tests;  (5;  inciex  card 
catalogue  of  plans. 

NUISANCES 

Inspector's  report  (a  form  8 J  by  II  inches,  to  which  duplicates  of 
notices,  etc.,  may  be  attached,  and  which  may  be  folded  twice  for  filing, 
is  convenient). 

Notice  blanks^  (to  abate  nuisance,  make  sewer  connection,  etc. J  in 
proper  legal  form. 

Inspector's  notification  blank  (sec  under  "oral  notification,"  p.  447). 

Reinspection  slip  (to  be  used  as  inspector's  memorandum  until  nui- 
sance is  abated). 

Special  forms  for  ffy  and  mosquito  inspections  and  notices,  etc. 

"  No  spitting  "  placards  for  public  buildings,  etc.,  and  warning  cards 
or  slips  for  spitters  (for  use  by  police,  street-car  conductors,  etc.),  if 
required. 

VITAL   STATISTICS  2 

Standard  birth  and  stillbirth  certificates. 

Blank  for  supplementary  report  of  given  name  of  child,  with  explan- 
atory slip  to  accompany  same. 
Standard  death  certificate. 
Burial  and  removal  permits. 

Transcript  books  for  preserving  local  copies  of  records. 
Forms  for  certified  copies. 

PERMITS 
Application  and  permit  forms. 

PUBLICITY 

Various. 

REGULATIONS 

Health  authorities  should  keep  in  print  their  ordinances  in  the  form 
of  an  indexed  code.  Printed  copies  of  sections  or  articles  dealing  with 
specific  subjects,  such  as  communicable  disease,'  milk,  etc.,  should  also 
be  kept  on  hand.  If  ordinances  are  published  in  newspapers,  reprints 
should  be  ordered  at  time  of  publication. 

1  In  some  cases  a  special  letter  is  preferable  to  the  printed  form. 

2  Vital  statistics  forms  should  be  uniform  and  should  be  furnished 
by  the  state  bureau  of  vital  statistics. 

'  The  Montclair,  N.  J.,  Board  of  Health  publishes  a  pamphlet  of 
"  Rules,  Regulations  and  General  Information  Concerning  Com- 
municable Diseases  "  for  distribution  to  physicians,  school  authorities, 
etc.,  which  is  an  excellent  example  of  what  may  be  done  in  this  line. 


APPENDIX  I 

NEW  YORK  STATE  SANITARY   CODE 

Following  the  recent  reorganization  of  the  New  York  State  Depart- 
ment of  Health,  with  special  reference  to  the  improvement  of  local 
administration,  the  first  and  chief  duty  of  the  Public  Health  Council 
was  the  framing  of  a  Sanitary  Code  to  apply  to  the  entire  State  with 
the  exception  of  New  York  City. 

The  aim  of  the  Council  in  this  imix^rtant  work  was  "to  secure  to  the 
citizens  of  the  State  all  the  ad\'antagcs  which  science  and  experience, 
especially  during  the  last  quarter  of  a  century,  have  offered  in  the  pre- 
vention of  disease  and  in  the  promotion  of  the  common  welfare,  with 
the  least  possible  interference  with  the  business,  comfort  and  convenience 
of  the  people  concerned."  And,  further,  "to  eliminate  .  .  .  the  use- 
less sanitary  procedures  which  mark  the  views  and  practices  of  an 
earlier  day,  now  replaced  by  exact  knowledge;  to  abandon  in  its  text 
those  technical  terms  which  though  still  often  used  have  lost  their 
earlier  meanings  and  values,  and  also  those  which  are  not  readily 
comprehensible  to  the  citizens  for  whose  use  and  guidance  the  code  is 
framed." 

Of  special  interest  are  the  regulations  relating  to  the  control  of  com- 
municable disease,  from  which  the  following  declarations  as  to  incuba- 
tion periods  and  isolation  are  taken. 

Regulation  35.  Maximum  period  of  incubation.  For  the  pur- 
pose of  this  code,  the  maximum  period  of  incubation  (that  is, 
between  the  date  of  the  exposure  to  disease  and  the  date  of  its 
development),  of  the  following  communicable  diseases  is  hereby 
declared  to  be  as  follows: 

Chickcnpox 21  days 

Measles 14  days 

Mumps 21  days 

Scarlet  fever 7  days 

Smallpox 20  days 

Whooping  cough 14  days 

Regulation  36.  Minimum  period  of  isolation.  The  minimum 
period  of  isolation,  within  the  meaning  of  this  code,  shall  be  as 
follows: 

632 


APPENDIX  I  633 

Chickeiipox,  until  twelve  days  after  llu-  appearance  oi  the  eriiij- 
tion  and  iinlil  the  crusts  have  fallen  and  the  scars  arc  completely 
healed. 

Dil)hthcria  (membranous  croup),  until  two  successive  negative 
cultures  have  been  obtained  from  the  nose  and  throat  at  intervals 
of  twenty-four  hours. 

Measles,  until  ten  days  after  the  appearance  of  the  rash  and  until 
all  discharges  from  the  nose,  ears  and  throat  have  disappeared  and 
until  the  cough  has  ceased. 

Mumps,  until  two  weeks  after  the  appearance  of  the  disease  and 
one  week  after  the  (lisap]jearance  of  the  swelling. 

Scarlet  fever,  until  thirty  days  after  the  development  of  the 
disease  and  until  all  discharges  from  the  nose,  ears  and  throat,  <jr 
suppurating  glands  have  ceased. 

Smallpox,  until  fourteen  days  after  the  development  of  the 
disease  and  until  scabs  have  all  separated  and  the  scars  completely 
healed. 

Whooping  cough,  until  eight  weeks  after  the  development  of  the 
disease  or  until  one  week  after  the  last  characteristic  cough. 

This  Code,  which  is  the  latest  word  in  sanitary  regulations,  covers  in 
some  detail  the  control  of  communicable  disease  and  the  other  branches 
of  sanitary  administration,  including  classification  of  milk  supplies. 
For  further  details  the  reader  is  referred  to  the  printed  regulations, 
which  may  be  obtained  from  the  State  Department  of  Health,  Albany, 
N.  Y. 

The  Public  Health  Council  also  fixes  the  qualifications  of  division 
directors,  sanitary  supervisors,  health  officers  and  public  health  nurses, 
and  regulates  midwifery.  A  subject  of  peculiar  interest  dealt  with  by 
the  regulations  is  that  of  labor  camps. 


INDEX 


Actinomycosis,  402. 

Acute  anterior  poliomyelitis,  243, 

294. 
Administration,  local,  27. 

joint,  29. 
Adulteration  of  foods,  399. 
ACstivo.     See  Estivo. 
Age-groups  in  population,  510. 
Air,  infection  through,  119. 

poisoning    of,    by    illuminating 

gas,  427. 
smoke,  dust  and  gases  in,  476  ff. 
Air  supplies.     See  Ventilation. 
American      Journal      of      Public 

Health,  60. 
American  Public  Health  Associa- 
tion, 60. 
Anchylostomiasis,  205. 
Anthrax,  250. 

spores,  destruction  of,  571. 
Antiseptics,  569. 
Antitoxin,  diphtheria,  137,  140. 

tetanus,  247. 
Antitoxins  and  vaccines,  furnished 
by  state  authorities,  33. 
supervision  of  manufacture  of, 
44. 
Appropriations,  7,  96. 
Asepsis,  569. 

and  disinfection,  123. 
Aseptic  methods  in  isolation  hospi- 
tals, 117,  121. 
Atypical  cases.     See  Missed  cases. 
Averages,  501. 

B.  coli  in  water  supplies,  406. 
Bacillus-carriers.     See  Carriers. 


Bacteria,     in     decomposition     of 
milk,  346. 

and  theory  of  infection,  106  ff. 
Bakeries,  402. 
Barber  shops,  265. 
Baths,  public,  disinfection  of,  2(>G. 
Bertillon  System,  514. 
Beverages,  commercial,  417. 

lead  in,  407. 
Births,  519. 

certificates  of,  522. 

premature,  statistical   rules  re- 
garding, 613  f. 

records  of,  value  of,  519. 

reporting  of,  492,  521. 
checks  upon,  494. 

supplementary  name  reports  of, 
521. 

statistical  rules  regarding, 613  ff. 

See   also    Stillbirths    and    Vital 
records  and  statistics. 
Birth  rate,  521. 

relation  of,  to  death  rate,  517. 
Blindness,  preventable,  239. 
Board  of  health,  local,  6. 

composition  of,  6. 

status  of,  7. 

appropriation  to,  7. 

See  also  Local  health  authorities. 
Board  of  health  physician,  18. 

and  tuberculosis,  174. 
"Bob  veal,"  402. 

Books,    and    communicable    dis- 
ease, 263  f. 

disinfection  of,  586. 
Botulismus,  401. 
Brill's  disease,  211. 


635 


636 


INDEX 


Buildings,  private.    See  Dwellings. 

public,  425. 
Bulletins,  health,  552. 

state  health,  36. 
Butter,  393. 

Carrier,  milk-borne  typhoid  fever 

epidemic  due  to,  284. 
Carriers,  107  ff. 

chronic  and  transitory,  109. 
dijjhtheria,  141  ff. 
in  institutions,  145. 
among  school  children,  142  ff. 
treatment  of,  144  f. 
disinfection  of  hands  of,  585  f. 
in  causation  of  epidemics,  274. 
frequency  of,  in  various  diseases, 

109. 
supervision  of,  no  fT. 
treatment  of,  no,  144  f. 
typhoid,  III,  188,  198,  199,  200, 
284. 
Case  fatality,  516. 
Cemeteries,  461. 
Censuses,  498,  503. 
Cerebrospinal  fever,  157,  294. 
Cesspools,  457. 
Charts.     See  Diagrams, 
Chickenpox,  245,  632  f. 

distinguished     from     smallpox, 
214. 
Child  hygiene,  296.     See  also  In- 
fant hygiene. 
Cholera,  203. 

"Cholera,"  infantile,  etc.,  204. 
Cleanliness,  as  disinfectant,  570. 

personal,  value  of,  115  ff. 
Cleansing,  after  tuberculosis,  176. 
"Clean-ups,"  446. 
Climate,    influence    of,    on    mor- 
tality, 511. 
Clinics,  tuberculosis,  177. 
Closets,  sanitary,  454. 


Colds,  186. 

Colon  bacillus.     See  B.  coli. 

Common     drinking    cups,     roller 

towels,  etc.,  264,  404. 
Communicable  disease,  loi. 
advice  and  action  on,  by  state 

authorities,  32,  39. 
chief,   important  data  concern- 
ing, 294. 
classification    of,    by    modes    of 

transmission,  loi. 
control  of,  102. 

summarized,  122. 
diagnosis  of,  doubtful,  102. 
effects    of,    other    than    direct 

mortality,  78  f. 
hospital  methods  in,  117,  121. 
hospital  for.     Sec  Isolation  hos- 
pital, 
and  infants,  303,  315. 
investigation    and    action    con- 
cerning, 104. 
and  libraries,  263. 
and  milk,  368. 

mild  cases  of,  unreported,  102. 
plural  infections  in,  102. 
recording  of,  104. 
references  on,  293. 
regulations    for,    N.    Y.    State, 

632  f. 
reporting  of,  102. 
and  season,  511. 
state  authorities  in  relation  to, 

32  f.,  39- 

and   schools.     See  Schools  and 
School  children. 

suspected  cases  of,  102. 

terms  relating  to,  loi. 

See  also    Infection,    Epidemics, 
Carriers,  Missed  cases.  Iso- 
lation,    Quarantine,      Dis- 
infection. 
Computation,  methods  of,  532. 


INDEX 


637 


Confectioneries,  402. 

Congenital  malformation  anrl  flc- 
bility,  304. 

Congestion  and  death  rates,  512. 

Consultation    stations.     See     In- 
fant hygiene  stations. 

Contact  infection.     See  under  In- 
fection. 

Contacts,  surveillance  of,  131. 

Contagious.     See  Communicable. 

Cooperative     health     administra- 
tion, 619. 

"  Correction  "  of  rates.    See  Stand- 
ardization. 

Costs  of  public  health  work,  96. 
in     improving     milk     supplies, 

393  f- 

vs.  results,  272. 

of  infant  hygiene  work,  339. 
Cream,  391.     See  also  Milk, 
adulterants,  etc.,  in,  390. 
"dipped,"  in  stores,  382. 
Creameries.     See    Milk    shipping 

establishments. 
"Croup."     See  Diphtheria. 
Cuspidors,  public,  476. 

Dairies,  and  communicable  disease, 
368. 

inspection  of,  373. 

water  supplies  for,  417. 
Dairy  score-card,  373. 
Dead  animals,  disposal  of,  459  ff. 
Dead  bodies,  care  of,  136. 

disposal  of,  461. 
Death,  causes  of,  73  fT.,  513  ff. 

certificates  of,  errors  in,  517. 

See  also   Infant   mortality  and 
Vital  statistics. 
Deaths,  non-resident,  507. 

recording  of,  493. 
checks  upon,  496. 

statistical  rules  regarding,  612  ff. 


Dealiis,  See  also  Vital  records  and 

.statistics. 
Death  rates,  507. 
and    birth    rates,    relation    be- 
tween, 517. 
by  cause,  513,  515. 
definitions     and     formulas     of, 

507  ff. 
excessive,  540. 

factors  determining,  92  f.,  510. 
precision  of,  535. 
reduction  of  limits  to,  518  f. 
specific,  513. 
standardization  of,  508. 
study  and  interpretation  of,  513, 

516,  518  f. 
urban  and  rural,  48  f. 
in  U.  S.  Registration  Area,  71  ff. 
by  age,  73,  74. 
by  cause,  75  ff. 
Demography,  503. 
Deodorants,  569,  591. 
Desquamation,    as   source    (?)    of 
infection,  112. 
in  scarlet  fever,  147  f. 
Diagnosis,  doubtful,  102. 
Diagrams,  536. 

titles  for,  537. 
Diarrhoeal  diseases,  204. 

infantile,  204,  302. 
Diphtheria,  136,  294. 

bacteriological     diagnosis     and 

control  of,  138,  146. 
carriers  of,    numbers  and   con- 
trol of,  109,  141  ff. 
in  institutions,  145. 
among  school  children,  142  ff. 
treatment  of,  144  f. 
epidemics  of,  290  f. 
immunization    against,    of    ex- 
posed persons,  137. 
in  institutional  outbreaks,  145. 
incidence  of,  138. 


638 


INDEX 


DiplUlicria,  isolation  of,  141. 
length  of,  146. 

terminal     disinfection     after, 
146. 
and  milk  supplies,  369. 
in  relation  to  schools: 
school  epidemics,  143. 
exclusion  of  school  children, 
146. 
transmission,  138. 
Diphtheria  antitoxin,  use  of,  137. 
furnished  by  health  authorities, 
140. 
Dirt,  sanitary  significance  of,  83. 
Diseases,  preventable,  73  ff.,  loi. 

of  occupation,  435  ff". 
Diseases    not    subject    to    public 

health  measures,  79. 
Disinfectants,  570. 

action   of,   afTected   by   organic 

matter,  576. 
household,  590. 
prescribed     and     supplied     by 

health  authorities,  581. 
standardization  of,  590. 
for  specific  uses,  581.     See  under 
Disinfection.   * 
Disinfectant  agents: 
physical: 

cleanliness,  570. 

heat    (burning,    boiling,    dry 

heat  and  steam),  571  f. 
sunlight,  571. 
chemical: 

bichloride  of  mercury,  575. 
carbolic  acid,  574. 
cresols,  574. 
formaldehyde  gas,  576. 

methods  of  production  of, 

579- 
testing  of  efficiency  of,  578. 
formalin,  575. 
hydrocyanic  acid  gas,  588. 


Disinfectant  agents,  chemical: 
lime,  572. 

lime,  chlorinated,  573. 
sulphur  dioxide  gas,  588. 
Disinfection,  569. 

against  anthrax,  250  f.,  571. 

of  bedding,  586. 

of  body  and  bed  linen,  586. 

of  books,  586. 

defined,  569. 

of  discharges,  etc.,  123. 

of  dishes,  etc.,  586. 

of  e.xcreta,  582. 

gaseous,  131,  576. 

testing  of  efficiency  of,  578. 
of  the  hands,  585. 
of  miscellaneous  articles,  586. 
of  public  baths  and  swimming 

pools,  266. 
references  on,  593. 
after  removal  to  hospital,  129. 
of  rooms,  576  fT.,  587. 
of     sputum,     discharges     from 
mouth  and  nose,  etc.,  582. 
of  stables,  588. 
of  surfaces,  587. 
terminal,  131,  576,  587. 

abandoned  in  Providence  and 
N.  Y.  City,  132. 
after  tuberculosis,  134,  175. 
of  water  supplies,  412. 
of  wells,  417. 
Dogs,  registration  and  control  of, 

223  {{. 
Dog-bites,  action  in  case  of,  226  ff. 
Drinking  cups,  common,  264. 
"Droplet"  infection,  114. 
Drug  habit,  253. 
Drugs,  41. 
Dust,  indoor,  478. 
Dust  nuisance,  477. 
Dwellings,  types  of,  423. 
Dysenteric  diseases,  204. 


FNDIOX 


<339 


Economic    coiiflitions   and    dcatli 

rates,  92  f.,  511  f. 
Economic  value  of  puljlic  hcallli 

woric,  95. 
Education    of    public.     See    Pub- 
licity. 
Endemic,  267. 

Enteric  fever.     See  Typhoid  fever. 
Enteritis.      Sec     Diarrhoeal     dis- 
eases. 
Epidemics,    carriers    and    missed 
cases  in  causation  of,  274. 
curves  of,  274. 
examples  of,  275. 

contact     infection     (typhoid 

fever),  275. 
milk  infection  (scarlet  fever), 

281. 
milk    infection     (septic    sore 

throat),  288. 
milk  infection  (typhoid  fever 

carrier),  284. 
shellfish     infection     (typhoid 

fever),  284. 
water       infection       (typhoid 
fever),  278. 
investigation  of,  268. 
milk-borne,  summary  of,  289. 
points  of   interest   in  report- 
ing, 292. 
prevention  of,  267,  272. 
primary  and  secondary  cases  in, 

274. 
publicity  regarding,  550. 
types    and    characteristics    of, 

273- 

See  also  under  names  of  diseases. 
Epidemiology,  266. 

terms  pertaining  to,  267. 

references  on,  293. 
Epizootic,  267. 
Estivo-autumnal  fever,  207. 
Excreta,  disinfection  of,  582. 


ExrnMa,  flisposal  of,  448,  454. 

removal  of,  from  j^rivics,  456. 
lOxhihitions.     See  Publicity. 
Ex])cnditurc;s.     See  Costs. 
Eye  inflammation  in  infants,  241. 

prevention  of,  240. 

Factories,  434  ff. 

state  supervision  over,  42,  436. 
Fallacies,  public  hcaltli,  83. 

statistical,  526. 
Farcy,  248. 

Federal  health  authorities  and  or- 
ganization, 52. 
advisory  functions,  52. 
executive  functions,  53. 
proposed  reorganization  of,  56. 
Federal  bureaus,  54. 
Flies,  as  conveyers  of  disease,  209, 
461. 
in  typhoid  fever,  190. 
manner  of  breeding  of,  462. 
measures  against,  463. 

urban  and  rural,  467. 
references  on,  468. 
Fly-traps,  467. 
Fomites  infection,  118. 
Food    (esp.    meat)    infection   and 

poisoning,  400  flf. 
Food  and  drink  as  vehicles  of  in- 
fection, 118,  199.    . 
Foods,  establishments  where  pre- 
pared, exposed,  etc.,  402. 
other    than    milk,     objects    of 

regulation  of,  398. 
publicity  regarding,  404. 
references  on,  404. 
typhoid   fever  transmitted   by, 
191. 
Foods  and  drugs,  relation  of  state 

authorities  to,  41. 
Foot-and-mouth  disease,  354. 
Forms  for  health  offices,  629. 


640 


INDEX 


Fruit..    See  Vegetables. 
Funeral  restrictions,  136. 

Garbage  and  offal,  care  and  dis- 
pos;il  of,  458  ff. 

Garbage  dumps,  460. 

Gas,  illuminating,  air  poisoning 
by,  427- 

Gas  piping  and  fixtures,  inspec- 
tion of,  428. 

Gases,  deleterious,  in  air,  478. 

German  measles,  154. 

Germs.  See  Pathogenic  micro- 
organisms. 

Glanders,  248. 

Gonorrhoea.  Sec  Venereal  dis- 
ease. 

Gonorrhtt-al  ophthalmia,  239. 

Hands,  cleanliness  of,  115  ff. 
Health.     See  Public  health. 
Health  officer,  3,  12. 

and  board,  4. 

training   and   qualifications   of, 

14.  35- 
Health  officers'  associations,  65. 
Hog    cholera    infection   of    meat, 

400. 
Hookworm  disease,  205. 
Hospitals   and   sanitoria,   relation 
of  state  authorities  to,  44. 
for  tuberculosis,  177  ff. 
See  also  Isolation  hospitals. 
House-to-house  inspections,  431. 
Housing,  420. 

general  considerations  on,  421. 
in  infant  hygiene,  329. 
problem  of,  how  to  attack,  429. 

summarized,  433. 
references  on,  434. 
See  also   Buildings  and   Dwell- 
ings. 
Hydrophobia.     See  Rabies. 


Hygiene,    industrial.     See    Indus- 
trial hygiene, 
public.     See  Public  health. 

Ice  supplies,  418. 

and  typhoid  fever,  189,  418. 
Ice-cream,  391. 
as   possible   vehicle   of   typhoid 
fever,  190. 
Illuminating  gas,  air  poisoning  by, 

427. 
Incubation  periods,  294,  632. 
Industrial  hygiene,  434. 

references  on,  437. 
Infants,  eye  inllammation  in,  241. 
eyes  of,  prophylactic  treatment 
of,  240. 
Infant  hygiene,  300. 

costs  and  results  of  work  for,  339. 
history  of,  307. 
home  instruction  in,  308  ff. 
on  clothing,  315. 
on  communicable  disease,  315. 
on  feeding,  309. 
on  nostrums,  etc.,  315. 
on  milk,  310  ff. 
on  ventilation,  314. 
housing  and  general  sanitation 

in,  329. 
"little  mothers"  in,  327. 
control  of  mid  wives  in,  331. 
and  milk  supplies,  328. 
organization  of  work  for,  333. 

in  small  towns  and  cities,  336. 
postnatal  work  in,  306. 
prenatal  work  in,  306,  330. 
references  on,  344. 
results  of  calculation  of,  343. 
underlying  conditions  in,  306. 
unofficial  organizations  in,  329. 
working  mothers  and,  333. 
Infant  hygiene  nurse,  308  ff. 
general  functions  of,  316,  334. 


INDKX 


641 


Infant      hygiene      stations,     318, 

334  ff- 
commuMicablc  disease  to  Idc  rc- 
I)ortccl  to,  105. 
Infant  mortality,  300. 
causes  of,  301. 
by  age,  306. 
reduction  of,  307. 
prevcntability  of,  304. 
in  U.  S.  Registration  Area,  72. 
Infant  mortality  rates,  305. 

expression  of,  516. 
Infantile  diarrha-a,  204. 
Infantile  paralysis,  243,  294. 
Infection,  modern  theory  of,  106. 
modes  of: 
air,  119. 
contact,  113. 

epidemiological    character- 
istics of,  273. 
prevention  of,  115  ff.,  264. 
epidemic  of,  typhoid  fever, 

275- 
"droplet,"  114. 
fomites,  118. 
food  and  drink,  118. 
insects,  120. 
special,  120. 
summary,  121. 
sources  of,  112. 
types  and  characteristics  of, 

273- 
See  also   Communicable   dis- 
ease and  Epidemics. 
Influenza,  186. 

Insects  (and  vermin),  461-475. 
destruction  of,   by  fumigation, 

588,  592. 
as  disease-conveyers,  120. 
diseases  spread  by,  206. 

epidemiological      characteris- 
tics of,  274. 
Insecticides,  592. 


Inspectors,  duties  anri  training  of, 

17.  35-  37"  f- 
Instructive     nurse.      Sec     I'ublic 

health  nurse. 
International      Classification      of 

Causes  of  Death,  514. 
Investigation  and  advice,  by  Fed- 
eral authorities,  52  f. 
by  state  authorities,  32. 
See  also  Surveys. 
Isolation,  124. 

application  of  principles  in,  130. 
periods  of,  295,  632. 
revisits  to  cases  under,  129. 
Isolation  hospitals,  134. 
aseptic  methods  in,  117,  121. 
removal  to,  129. 
compulsory,  135. 
in  tuberculosis,  179. 
^eea^jo  Hospitals  and  Sanatoria. 

Joint  administration,  29,  619. 
in  milk  control,  370  f. 

Laboratory,  local,  21,  608. 

state,  local  service  by,  33. 
Laboratory  analysis,  of  milk,  384. 

of  water,  405. 
Laboratory  references,  611. 
Law.     See  Sanitary  law. 
Lantern  slides,  566  f. 
Lead   poisoning   from   water   and 

other  beverages,  407. 
Lectures,  562,  564. 
Legal   service.     See   wider   Local 

health  department. 
Leprosy  (Lepra),  252. 
Libraries  and  communicable   dis- 
ease, 105,  263. 
"Little  mothers,"  327. 
Local  health  authorities,  3. 

executive  staff  of,  11,  12. 

efficiency  of,  27. 


64- 


INDEX 


Local  health  authorities,  forms  for 
recording  work  of,  6^9. 
organization  of,  4. 

in  small  communities,  28. 
powers    and    procedure    of,    8. 
See    also    under    Sanitary 
law. 
references  on,  30. 
and  state  authorities,  44. 
Local  health  department:  inspec- 
tion, 17. 
public  health  nurse,  19. 
labor,  22. 
laboratory,  21,  608. 

references  on,  611. 
legal  counsel  and  service,  22. 
medical  service,  18. 
office,  23. 

veterinary  service,  22. 
Local  health  ordinances,  480. 
Local   registrar,   appointment    of, 
by  health  authorities,  40. 

Maggot  traps,  465. 

Malaria,  207. 

Malignant  pustule,  250. 

Malta  fever,  354. 

Manure,  459,  461,  463. 

Maps,  537. 

Marine  quarantine,  43. 

Markets,  403. 

Marriages,     and     marriage     rate, 

519- 
recording  of,  494. 
checks  upon,  496. 
Maxima  and  minima,  502. 
Measles,  150,  294. 
Measles,  German,  154. 
Meats,  399. 

infection  and  poisoning  through, 
400  fT. 
Median,  502. 
Medical  frauds,  254. 


Medical  inspection  of  school  chil- 
dren, 260,  296. 
references  on,  300. 
Meningitis,    epidemic    cerebrospi- 
nal. Sec  Cerebrospinal  fever. 
Mental  diseases,  253. 
Midwives,  control  of,  331. 
Mild  and  atypical  cases,  131.     See 

also  Missed  cases. 
Milk,   adulterants  and   preserva- 
tives in,  348. 
tests  for,  390. 
bacteria    in    decomposition    of, 

346. 
contaminated,  effects  of,  347. 
"dipped"  or  "loose,"  381  ff. 

decision  regarding,  25. 
fats  in,  388. 
home  care  of,  313,  384. 
home  modification  of,  310. 
home  pasteurization  of,  311. 
for  infants,  310  ff. 
pasteurization  of,  354,  369. 
argument  for,  356. 
cautions  in  connection  with, 

358. 
control  of,  358. 
definition  and  effects  of,  354. 
methods  of,  359. 
quarantine   regulations   regard- 
ing, 127. 
references  on,  397. 
skim,  393,  390. 
solids  in,  388. 
sterilization   of,    by   electricity, 

361. 
tests  of: 

bacteriological,  386. 
chemical,  388. 
microscopical,  391. 
for    sediment    (visible    dirt), 

389- 
watering  and  skimming  of,  390. 


INhKX 


64.3 


Milk  bottles  anri  utensils,  sterili- 
zation of,  379. 
Milk  containers,  cleansing  of,  3H0. 
Milk  insi)ector,  370  f.,  396  f. 
Milk     products,     391.     See     also 

Milk. 
Milk  shipping  and  bottling  estab- 
lishments, 375. 
Milk  sickness,  354. 
Milk  Standards,  Commission  on, 

362. 
Milk    stations.     See    Infant    hy- 
giene stations. 
Milk  stores,  381. 
Milk  wagons,  381. 
Milk  supplies,  345. 
certified,  366. 
classification  of,  363. 
improvement  of,  benefits  of,  347. 

economic  problem  of,  393. 
and  infant  hygiene,  328. 
inspection  of,  370. 
pasteurized,  standard  rules  for, 

364  fT. 
publicity  regarding,  395. 
regulation  of,  361. 
methods  of,  369. 
by  inspection,  370. 
by  laboratory,  384. 
objects  of,  361. 
organization  for,  395. 
requirements  for,  345. 

minimum,  373. 
special,  367. 
standards  for,  362. 

enforcement  of,  393. 
standard   rules   for   production, 
handling   and    distribution 
of,  593- 
tests  of,  frequency  of,  391. 

collection  of  samples  for,  384. 
in  transit,  inspection  of,  379. 
temperature  of,  380. 


Milk    supplies,    liilK^rciiiin-lcsi  iii^ 
of,    legal    ticc.isions    regard- 
ing,   604. 
water    supplies    in    connection 

with,  417. 
See  also  Dairies. 
Milk-borne  disease,  348. 

bovine  tuberculosis,  160,  349  ff. 
other  diseases  of  animal  origin, 

354- 
of  human  origin,  349. 

precautions  against,  368. 
typhoid  fever,  190. 
pasteurization    as    a    safeguard 

against,  356  ff. 
septic  sore  throat,  245. 
Milk-borne  epidemics,   character- 
istics of,  273. 
examples  of: 

scarlet  fever,  281. 
septic  sore  throat,  288. 
typhoid  fever  (carrier),  284. 
points  of  interest  in  reporting, 

292. 
summar}'  of,  289. 
Mim's  culicide,  592. 
Missed  cases,  107  ff. 

in  causation  of  epidemics,  274. 
Montclair,   N.   J.,   tuberculin-test 

case,  604. 
Morbidity  records  and  statistics, 

523- 
collected   by  state    authorities, 

39  f- 
Morbilli.     See  Measles. 
Mortalit}'.     See  Death  rates. 
Mosquitoes,  breeding  of,  469. 

breeding-places  of,  471. 

diseases  conveyed  by,  207. 

kinds  of,  469,  470. 

references  on,  474. 

suppression  of,  468. 

permanent  measures  for,  472. 


644 


INDEX 


Mosquitoes,   temporary   measures 

for,  473. 
Motion  pictures,  567. 
Mumps,  186,  632  f. 

National.     Sec  Federal. 
Negro  mortality,  510. 
New  York  Milk  Committee,  stand- 
ard rules  of,  594. 
New  York  State  plan  for  control 

of  rural  districts,  50  f. 
New  York  State  sanitary  code,  632. 
Newspapers,  546  ff.,  566. 
Night  soil,  disposal  of,  455. 

systems  of  removal  of,  456. 
Noise  nuisance,  478. 
"Normal"  rates,  etc.,  501. 
"Noxious"  trades,  478. 
Nuisances,  439. 

classifications  of,  440. 
classes  of: 

due  to  dust,  477. 

excreta,  448. 

gases,  478. 

insects     and     vermin, 

461. 
noise,  478. 

obnoxious  trades,  478. 
refuse,     various,     and 
uncleanliness,  458  ff. 
smoke,  476. 
spitting,  475. 
definition  of,  439. 
and    health,    relation    between, 

441. 
inspections  and  notifications  of, 

447- 
legal  remedies  for,  442. 
non-sanitary,  445. 
relation  of  state  authorities  to, 

39- 

Nurse,   in  communicable  disease, 
125. 


Nurse,  public  health.     See  Public 
health  nurse. 

Occupation,  diseases  of,  435  ff. 
statistical  rules  regarding,  612, 

618. 
Odors,  foul,  85. 
Ophthalmia  neonatorum,  239. 
Ordinances,  9,  480. 
Organization.     See    under    Local, 

State,  Federal,  Unofficial. 
Outbreaks.     See  Epidemics. 
Owen  Bill,  56. 
Oysters.     See  Shellfish. 

Paratyphoid  fever,  202. 

in  meat,  400  f.,  402. 
Pasteur  treatment  for  rabies,  227  f. 
Pasteurization.     See  under   Milk. 
Patent  medicines,  254. 
Pellagra,  251. 

Pertussis.     See  Whooping  cough. 
Picnic  grounds,  privies  for,  456. 
Plague,  210. 

Plumbing  inspection,  422,  445. 
Plural  infections,  102. 
Pneumonia,  155. 

"typhoid,"  187. 
Police,   cooperation  of,   in  abate- 
ment of  nuisances,  446. 
Poliomyelitis,  acute  anterior,  243. 
Popular  education.    See  Publicity. 
Population,  503. 

censuses  of,  503. 

composition  of,  by  age,  etc.,  510. 

estimation  of,  504. 
Posters,  health,  554. 
Prenatal  work  in  infant  hygiene, 

330. 
Preservatives,  348,  390,  399. 
Press,  the,  546. 

"Preventable"  and  "prevention" 
defined,  77,  79. 


INDEX 


04- 


Preventable  diseases,  73  (f.,  loi. 
Prevention,  cost  vs.  value  of,  272. 
Primary  and  secondary  cases,  274. 
Privies,  449. 

cleaning  service  for,  456. 

construction  and  care  of,  452. 

disposal   of   excreta   from,   454, 

455- 
fly-proofing  of,  in  reduction  of 

typhoid  fever,  466. 
sanitary  requirements  for,  449. 
sanitary  systems  of: 
"dry,"  450. 
"wet,"  451. 
for  schools,  etc.,  454. 
temporary,  455. 
Prosodemic,  267. 

Providence,  R.  I.,  terminal  disin- 
fection abandoned  in, 132. 
Providence,  R.  I.,  City  Hospital, 

117,  121. 
"Ptomaine  poisoning,"  402. 
Public  baths  and  swimming  pools, 

266. 
Public    health,    economic    factors 
in,  92. 
fundamental  needs  of,  80, 
the  new,  69,  88. 

compared  with  the  old,  82. 
quantitative  methods  in,  89. 
scope  of,  90. 
references  on,  97. 
uncontrollable  factors  in,  92. 
Public  health  authorities,  anoma- 
lous position  of,  82. 
limits  to  scope  of,  92. 
powers  of,  24. 

legal  decision  regarding,  606. 
See    also    under    Local,    State, 
Federal. 
Public  health  fallacies,  83. 
Public  health  movements,   auxil- 
iary, 64. 


I'ulJic  health  nurse,  19. 
in  infant  hygiene,  308  ff. 

general  functions  of,  316,  334. 
in  tuberculosis,  169  fT. 
Public  health  problems,  71. 

statistical  survey  of,  71. 
Public  health  science,  G9. 
Public    health    surveys   and    ]>ro- 

grams,  97. 
Public  health  terms  defined,  70. 
Public  health  work,  costs  of,  96. 
vs.   value    of,    540.     See   also 
Prevention, 
economic  value  of,  95. 
motives  for,  95. 
obstacles  to  progress  in,  93. 
See  also  Sanitation. 
Publicity,  92,  542. 

and  administration,  568. 
modes  of: 

exhibitions,  556. 

special  material  for,  563. 
traveling,  38,  563. 
exhibits,  small,  564. 
lectures,  562,  564. 
motion  pictures,  567. 
the  press,  546. 
printed  matter,  552. 
objects  of,  542. 
principles  of,  543. 
by  state  health  authorities,  37. 
distribution  of,  554. 
technique  of,  555. 

Quarantine,  126. 

application  of  principles  to,  130. 

marine,  43. 
Quartan  fever,  207. 
Quetelet's  rules,  538. 

Rabies,  218,  294. 

diagnosis    and    recognition    of, 
221  f. 


646 


INDEX 


Rabies,  information  to  dog-owners 
regarding,  224  f. 
incidence  of,  220. 
incubation  period  of,  219. 
ordinance  regarding,  229. 
prevention  of,  223. 
in  general,  223. 
in  specific  cases,  226. 

Pasteur  treatment  for,  227  f. 
state  system  for,  231. 
references  on,  233. 
transmission  of,  219. 
types  of,  221. 
Race,   influence  of,  on  mortality, 

510. 
Railroad  sanitation,  43,  409. 
Ratios  and  rates,  501. 
fallacies  in,  526. 
precision  of,  535. 
See  also  Vital  statistics. 
Rats,  210,  460. 
Records,  forms  for,  629.     See  also 

Vital  records. 
Refuse,     care    and    disposal     of, 

458  ff. 
Registration,  39,  492. 
Registration  Area,  498. 
Registration  States,  539. 
Relapsing  fever,  211. 
Report,  annual,  486. 

distribution  of,  488,  554. 
press  notice  regarding,  488. 
publicity  through  reprints  from, 

553- 

standard  plans  for,  487,  622. 
Reports,  statistical,  rules  regard- 
ing, 614,  617. 

weekly  and  monthly',  486  f. 
Reservoirs,  safeguarding  of,  410. 
Restaurants,  403. 
Rubeola  (rubella),  154. 
Rural  districts,  state  control  of,  48. 

CJ.  Small  communities. 


Rural  and  urban  conditions  com- 
pared, 48  f.,  512. 

Sanitary.  See  also  Public  health. 
Sanitary  authority,  nature  of,  24. 
Sanitary  law,  8  f.,  480. 

advice  on,  by  state  authorities, 

33  f- 
enforcement  of,  482. 
notices  to  comply  with,  10,  482. 
ordinances  under,  adoijtion  of, 

9,  480. 
penalties  under,  481. 
procedure  under,  9  ff. 
prosecutions  under,  483. 
remedies  under,  481. 
references  on,  485. 
Sanitary  index,  proposed,  513. 
Sanitary     legislation,     tendencies 

in,  484. 
Sanitary      science.       See     Public 

health. 
Sanitation  and  death  rates,  512. 

See  also  Public  health. 
Sanatoria.        See    Hospitals    and 

sanatoria. 
"Sausage  poisoning,"  401. 
Scarlatina.     See  Scarlet  fever. 
Scarlet  fever,  147,  294. 
control  of,  149. 
epidemic  of,  due  to  milk,  281, 

290  f. 
incidence  of,  149. 
and  school  children,  150. 
transmission  of,  148. 
Schools: 

communicable  disease  in,  254. 
closure  on  account  of,  255. 
in  rural  districts,  259. 
in  urban  districts,  256. 
summary  remarks  on,  259. 
exclusions  on  account  of,  127, 
146,  254,  260. 


INDEX 


G47 


Schools,  coninnmicablc  disease  in: 
reporting  of,  102. 
communicabio     disease     to    be 

notified  to,  105. 
dipiitheria  epidemics  in,  143. 
iiygiene  and  sanitation  of,  261, 
299. 
references  on,  300. 
infant    hygiene    instruction    in, 

327- 
open-air,  299. 
sanitary  education  in,  262,  299, 

543- 
School    children,    diphtheria    car- 
riers among,  142  ff. 
medical  inspection  of,  260,  296. 

references  on,  300. 
vaccination  of,  217  f. 
Score-cards,  371. 

for  dairy  farms,  373. 

for      establishments      handling 

milk,  376. 
for  milk  stores,  381. 
Season  and  public  health,  511. 
Secondary  cases,  274. 
Septic  sore  throat,  245. 

milk-borne  epidemics  of,  288. 
Sewage  disposal,  448,  457. 
domestic  systems  for,  457. 
municipal,  458. 

relation  of  state  authorities  to, 
42. 
Sewer  gas,  85. 
Sewers,    house   connections   with, 

448. 
Shellfish-borne  typhoid  fever,  191. 

epidemic  of,  284. 
Sick-room,  124. 
"Skin  test,"  163. 

Small  communities,  problems  of, 
28. 
solved  by  joint  sanitary  ad- 
ministration, 29,  619. 


Smallpox,  211,  294. 

control  of,  212. 

diagnosis  of,  214. 

incidence  of,  212. 

modifiefl  by  vaccination  (vario- 
loid), 213. 

transmission  of,  211. 

See  also  Vaccination. 
Smoke  nuisance,  476. 
Soda  fountains,  etc.,  404. 
Soda  water.     See  Beverages. 
Spitting  nuisance,  475. 
Splenic  fever,  250. 
Springs.     See  Water  Supplies,  pri- 
vate. 
Standard  methods  and  forms,  34, 

534. 

Standard    plans    for    annual    re- 
ports, 487,  622. 

Standardization  of  statistics,  508, 

525- 
error  due  to  lack  of,  525. 
State  conferences,  34. 
State  health  authorities,  31. 
bulletin  in  service  of,  36,  37  f. 
functions  of,  31. 
advisory,  32. 
executive,  38. 
and  local  authorities,  34,  44,  48. 
local  powers  of,  44. 
and  milk  supplies,  395. 
organization  of,  46. 
state  sanitary   supervision   by, 
48. 
State  health  officers'  associations, 

65; 

State  registration  system,  39. 
Statistics.     See  Vital  statistics. 
Sterilization,  569. 

of  milk  bottles  and  utensils,  379. 
Stillbirths,  523. 

statistical  rules  regarding,  613, 
614,  615,  618. 


648 


INDEX 


Street  sweepings,  disposal  of,  459. 

Surveys  and  programs,  97. 

"Suspects,"  102.  See  also  Con- 
tacts. 

Swimming  pools,  disinfection  of, 
266. 

Syphilis.     See  Venereal  disease. 

Tables,  534. 

headings  of,  537. 
for  deaths,  614. 
preparation  of,  529. 
standard,  534,  616. 
Tabulation  systems,  529. 
Tapeworm,  402. 
Tenements,  423. 

and  state  authorities,  42,  432. 
Tertian  fever,  207. 
Tetanus,  246. 

antitoxin  for,  247. 
destruction  of  spores  of,  571. 
Tonsillitis,   epidemic.     See  Septic 

sore  throat. 
Towels,  common,  264. 
Trachoma,  242. 

Trades  deleterious  to  health,  512. 
Transportation,    hygiene    of,    43, 

409. 
Trichinosis,  402. 
Tuberculin,  in  diagnosis,  163. 
Tuberculin  test,  351. 

legal  decisions  regarding,  604. 
Tuberculosis,  158,  294. 
and  books,  264. 
bovine,  160,  349  fT. 
control  of,  162. 

bacteriological  diagnosis,  168. 
cases,  registration  of,  105  f., 

164. 
cleansing     and     disinfection, 

175- 
health  department  nurse,  1G9 
ff. 


Tuberculosis,  control  of: 

health  department  physician, 

174- 
home  supervision,  168  ff. 
housing,  factories,  etc.,  184. 
institutional  care  (clinics,  dis- 
pensaries, sanatoria,  hospi- 
tals), 177  fT. 
milk  supplies,  184. 
segregation,  compulsory,  179. 
popular  education  (publicity), 

181. 
various  agencies,  181. 
cooperation  of,  184. 
incidence  of,  161. 
infection: 

nature  of,  159. 
transmission  of,  160. 
in  meat,  402. 
in  milk,  160,  349  ff. 
progress  against,  184. 
references  on,  186. 
Typhoid  fever,  187,  294. 

bacteriological  examinations  for 
diagnosis,  196  f.   • 
for  release,  198. 
carrier  of,  milk-borne  epidemic 

due  to,  284. 
carriers,  109,  iii,  116,  188,  198, 
199,  200. 
disinfection  of  hands  of,  585  f. 
control  of,  195. 

fly-screening  in  reduction  of,  466. 
epidemics  of,  188,  191,  275,  278, 

284,  289  f. 
investigation  of,  268  ff. 
incidence  of,  192. 
inoculation  (vaccination) 

against,  194,  200. 
and  milk  supplies,  369. 
references  on,  203. 
residual,  192. 
transmission  of,  modes  of,  188. 


INDKX 


649 


Typhoid  fever,  wasiiiiif;  of  hands 
a  protection  against,  116. 
watersheds,     safeguarding      of, 
against,  408  f. 
Tyiiiius  fever,  211. 

Uncinariasis,  205. 
Universities  and  state  health  de- 
partments, 37. 
"Unknown"  numbers,  534,  617. 
Unofficial  organizations,  59. 

local,  67. 

national,  60. 

state,  65. 

infant  hygiene,  329. 

international,  65. 
Urban  and  rural  conditions  com- 
pared, 48  f.,  512. 
Urotropine,  199. 
U.  S.  Bureaus,  54. 
U.  S.  Registration  Area,  statistics 

of,  71  fi. 
U.  S.     See  also  under  Federal. 

Vaccination,  212  f.,  215  ff. 
Vaccines.     See      Antitoxins     and 

vaccines. 
Varicella.     See  Chickenpox. 
Variola.     See  Smallpox. 
Varioloid.     See  ufider  Smallpox. 
Veal,  402. 

Vegetables    and    fruits,    typhoid 
fever  conveyed  by,  191. 

decision    regarding    protection 
of,  26. 
Venereal  disease,  233. 
Ventilation,  425. 

infant  hygiene,  314. 

systems  of,  425. 
Vermin.     See  Insects. 
Veterinary  service,  22. 
Vital  records: 

copying,  transcribing  and  trans- 
mitting of,  497. 


Vital  records: 

recording  of,  492. 

tabulation  from,  529. 

uses  of,  491. 
Vital  statistics,  489. 

application  and  value  of,  489  fT., 

539- 
computations  in,  532. 
definition  of,  489. 
deficiencies  in,  538  f. 

in  data,  533. 
of  disease,  523. 
error  in,  sources  of,  524. 
methods  in,  529. 
official   (Federal,  etc.),  sources 

of,  498. 
of  population,  503. 
presentation  of,  498,  534. 
registration  of,  39,  492. 
references  on,  541. 
rules  for  practice  in,  612. 
rules  for,  Quetelet's,  538. 
of  states,  539. 
study    and    interpretation    of, 

497.  498,  538. 
theory  of,  499. 
See    also     Population,     Births, 

Deaths,  Marriages. 
Von  Pirquet  reaction,  163. 

Wassermann  test  for  syphilis,  236. 
Wastes,  disposal  of,  448,  458. 
Water,  bottled,  417. 

lead  poisoning  from,  407. 
running,      imaginary     purifica- 
tion of,  87. 
stagnant,  and  fevers,  86. 

breeding  mosquitoes,  469  fF. 
typhoid  infection  through,  189. 
Water  supplies,  405. 
analysis  of,  405. 

bacteriological,  405. 
chemical,  406. 


650 


INDEX 


Water  supplies,  for  dairy  purposes, 

374.  417- 
disinfection  of,  412. 
from  ground  sources,  409. 
inspection  of,  405. 
microscopic  examination  of,  406. 
official  responsibility  for,  413. 
pollution  of,  408  IT.,  414  ff. 

traced  by  dye,  415. 
private,  414. 

procedure  to  abolish,  417. 
public,  408. 
purification  of,  410. 
references  on,  418. 
reservoirs  for,  safeguarding  of, 

410. 
rural  and  urban,  compared,  416. 
state  authorities  in  control  of,  42. 


Water  supplies,  from  surface 
sources,  408. 

Water-borne  infection,  character- 
istics of,  273. 

Water-borne  diarrha^al  disease, 
189,  205. 

Water-borne  typhoid  fever,  189, 
278. 

Weather  conditions  and  mortal- 
ity, 511- 

Wells,  disinfection  of,  417. 

Wells.  See  Water  sup]jlies,  pri- 
vate. 

Whooping  cough,  154,  294. 

Widal  reaction,  196. 

Wool-sorters'  disease,  250. 

Yellow  fever,  208. 


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